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Nurses contribution to the resolution of ethical dilemmas in context
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Barlow, Nichola (2014) Nurses contribution to the resolution of ethical dilemmas in context. Doctoral thesis, University of Huddersfield.
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1
NURSES CONTRIBUTION TO THE RESOLUTION OF
ETHICAL DILEMMAS IN CONTEXT
Nichola Ann Barlow
A thesis submitted to the University of Huddersfield
in partial fulfilment of the requirements for
the degree of Doctor of Philosophy
The University of Huddersfield
November 2014
2
Abstract
Background: New nursing roles and advances in care and treatments have resulted
in nurses facing increasingly complex ethical dilemmas in practice; nurses are
therefore required to engage effectively in ethical decision-making.
Prior to commencing this empirical study a literature review was undertaken, the
databases CINAHL, Science Direct, Medline, Web of Science and British Nursing
Index were searched. Peer reviewed papers were systematically reviewed.
Emerging themes were moral distress, codes of ethics, conflict within ethical
decision-making and policy. The literature included international studies and
indicated that ethical decision making is a concern amongst nurses globally.
Aim: To identify how nurses contribute to the resolution of ethical dilemmas in
practice.
Method: An Interpretive Qualitative study was undertaken, between March and
December 2012, using a flexible approach to analysis. The National Research
Ethics Committee provided Ethical approval. Eleven registered nurses were
interviewed using semi-structured interview, focusing on how participants addressed
ethical dilemmas in practice. In-depth thematic and content analysis of the data was
undertaken. The relatively small, single site sample may not account for the affects
of organisational culture on the results.
Results: Four major themes emerged: ‘Best for the patient’, ‘Accountability’,
‘collaboration’ and ‘policy’. In addition professional relationships were identified as
key to resolving ethical dilemmas. Moral distress was evident in the data as
identified in the literature, and reflects the emotional labour nurses’ experience. Discussion: Support is required for nurses to acquire the skills to develop and
maintain professional relationships for addressing ethical dilemmas in practice.
Nurses require strategies to address the negative impact of moral distress.
Conclusion: Nurses’ professional relationships are central to nurses’ contributions
to the resolution of ethical dilemmas.
Recommendations: Research is required to explore this phenomenon in other
geographical areas and professional settings. Nurses need to engage with political
and organisational macro and micro decision making. Further research is required to
establish how nurses can manage moral residue and minimise the negative impact
of moral distress.
3
Acknowledgements
Thank you to my Director of Studies, Professor Janet Hargreaves, and
Academic Supervisor, Dr Warren Gillibrand, for their continued advice,
support and enthusiasm which sustained my motivation throughout the time
this has taken.
Thank to my friends and colleagues for their support without which I would not
have completed this thesis
Thank you to my family for their understanding and believing in me.
4
Contents
Abstract page 2
Acknowledgements Page 3
Contents Page 4
Tables and figure Page 7
Appendices Page 8
5
Section I
Chapter 1 - Background
1.0 Introduction Page 10
1.1 Context Page 13
1.2 Background page 15
1.3 Theoretical Framework page 20
1.4 Summary page 36
Chapter 2 –Literature review
2.0 Literature review Page 39
2.1 Search strategy Page 39
2.2 Critique Page 41
2.3 Results Page 42
2.4 Conclusion Page 61
2.5 The aim of the study Page 64
Chapter 3 – Study design
3.0 Study Design Page 66
3.1 Data collection Page 66
3.2 Pilot Study Page 67
3.3 Main study Page 72
6
Section II
Chapter 4 - Results
4.0 Results of the thematic analysis Page 87
4.1 participant profile Page 87
4.2 Results of the thematic analysis Page 87
Chapter 5 - Best for the patient
5.0 Best for the patient Page 92
5.1 Advocacy Page 93
5.2 Standard of care Page 100
5.3 Conclusion Page 108
Chapter 6 - Accountability
6.0 Accountability Page 109
6.1 Autonomy Page 113
6.2 Conclusion Page 122
Chapter 7 - Collaboration and conflict
7.0 Collaboration and conflict Page 124
7.1 Collaboration Page 124
7.2 Conflict Page 134
8.3 Conclusion Page 141
Chapter 8 - Concern for others
8.0 Concern for others Page 144
7
Section III
Chapter 9 - Case study
9.0 Case study Page 152
9.1 Reconceptualised theoretical framework Page 154
9.2Conclusion Page 167
Chapter 10 – Discussion
10 .0discussion Page 169
10.1 ethical dilemmas Page 169
10.2 The context Page 170
10.3 Moral Reasoning Page179
10.4 Ethical Decision-making Page 185
10.5 Moral Action Page 188
10.6 Moral Residue Page 196
10.7 Conclusion Page 201
Chapter 11 - Conclusion
11.0 Introduction Page 203
11.1 Contribution to nursing knowledge Page 205
11.2 Limitations of the study Page 207
11.3 Recommendations Page 208
11.4 Dissemination of the results Page 211
11.5 Reflection Page 212
11.6 Summary Page 225
Reference list Page 228
8
Contents
Tables
Table 1 Participant profile Page 75
Table 2 Themes from the thematic analysis Page 89
Figures
Figure 1 Theoretical framework Page 38
Figure 2 Reconceptualised theoretical framework Page 154
9
Appendix
Appendix 1: Table of selected literature (background) Page 243
Appendix 2 : Table of selected literature (Literature review) Page 247
Appendix 3: Review framework proforma Page 252
Appendix 4: Participant Information sheet (pilot study) Page 255
Appendix 5: Participant Consent form (pilot study) Page 257
Appendix 6: Participant Information sheet Page 261
Appendix 7: Participant Consent form Page 263
Appendix 8: European Doctorate Students Research Conference,
Abstract and PowerPoint presentation Page 264
Appendix 9: Undergraduate student research conference
PowerPoint presentation. Page 276
10
Chapter 1: Introduction
1. Introduction
This exploratory study investigates the contribution British nurses make to the
resolution of ethical dilemmas within the secondary care context. A registered nurse,
referred to within this thesis as the nurse, from any field, is one who is currently
registered with the Nursing and Midwifery Council (NMC), from any part of the
register, and, for this study, employed within secondary care provision and working
within the requirements of that registration. Throughout this paper the term nursing
practice will be used to refer to this context.
Decision making is an essential part of the nurse’s role (NMC, 2008); because
nurses are required to advocate for patients (NMC, 2008) this can lead to ethical
dilemmas and conflict with others involved in their care (Oberle and Hughes, 2001).
It is therefore important that nurses are able to justify their contribution to the
decisions made. However, whilst the decisions nurses make may be reflected upon
it is the values used to make these decisions which are often overlooked (Harris,
1985). The contributions that nurses make and the values on which such
contributions are based are the focus of this exploratory investigation.
The overall aim of the research is thus to identify the values, beliefs and contextual
influences that inform decision making and the contribution made by registered
nurses in achieving the resolution of ethical dilemmas in nursing practice. This
chapter will outline the structure of the thesis, locate the context in which it takes
place and present a theoretical framework to guide development of ethical decision
making.
11
Chapter 2 presents the results of the review of the literature, which identified four
themes: the role of ethical codes; the importance of policy; ‘moral distress’; and
conflict. In light of the study findings further literature has been reviewed to include
collaborative working, professionalism, advocacy and accountability and the impact
of both policy and organisational culture. This additional literature is included in the
Findings and Discussion chapters.
In order to address the aim of the research a qualitative approach was selected,
enabling the collection of rich, in depth data. Chapter 3 presents and justifies this
approach. A pilot study was conducted to determine the most appropriate data
collection method; because the select approach has proved to be an appropriate
choice the pilot data have been included in the analysis.
The transcripts of all the participants’ interviews underwent a content and
interactional analysis to identify contextual influences on the nurses’ contributions to
the resolution of ethical dilemmas. Four key themes: Best for the Patient;
Accountability; Collaboration and Conflict; and Concern for Others emerged and are
explored in detail in Chapters 4 – 8.
Chapter 9 presents a case study from ‘Charlie’, which critiques the theoretical
framework. A re-conceptualisation emerges, with the addition of relationships as
central to ethical decision making and the resolution of ethical dilemmas.
12
Chapter 10 explores the elements of the relationships that the data have identified as
central to the effective resolution of ethical dilemmas in nursing practice, in an
attempt to define what effective resolution might be. These findings appear to
endorse virtue ethics as central to understanding relationships and to add to our
understanding of their application in practice. Furthermore, moral distress emerges
as a consequence of ethical decision making and as an integral aspect of
relationship building in nursing.
Finally, Chapter 11 reprises the thesis and offers recommendations for further
research for nursing practice.
The discussion of the findings will argue that nurses do contribute to the resolution of
ethical dilemmas and that the nursing values they hold are influenced by their
personal, professional and cultural values. Perhaps more importantly, nurses’
values and beliefs are influenced by their professional experiences and the findings
indicate a strongly held conviction that nurses have a shared belief and value
system. The key to achieving moral action is through the relationships that nurses
negotiate and maintain with patients, their families and other health and social care
professionals. These relationships help nurses to understand the perspectives of the
patients and others on whom decisions will impact, thus enabling the moral actions
identified as best for the patients. Taking responsibility for decision making in this
situation and attempting to resolve ethical dilemmas contributed to the moral distress
that the nurses articulated in their narrative accounts.
13
1.1 The context in which nurses contribute to the resolution of ethical
dilemmas
The secondary care setting was selected for investigation as the context of this
setting, and the role nurses play within it, has changed significantly. Over the last
two decades demand for treatment and the options available have increased (Storch
et al., 2004). Policy directives, which include Our Health, Our Care, Our Say (DH,
2006) and the Expert Patient Programme (DH, 2001) have led to changing
expectations from patients who now recognise the importance of negotiated care
packages and of treatment options. The introduction of Foundation Trusts and
private health care companies now eligible to provide National Health Service (NHS)
funded care has influenced changes in care provision across this sector (DH, 2008).
These changes have resulted in role development for nurses (DH, 2005; 2008) and
new dilemmas to face (Storch et al., 2004).
Changes to the role of the nurse and the challenges faced by nurses have been
seen as so fundamental that they contribute to the changes in nurses’ preparation for
professional practice (Ramprogus, 1995; NMC, 2004; NMC, 2010a). Many of these
changes have been driven by government policy, which in turn has been informed by
public and patient expectations. For example, in the early days of nursing emphasis
was frequently put on a person’s character. These characteristics would include
patience, obedience, devotion and kindness (Storch el al., 2004). These authors
also suggest that the context in which people were cared for in the 1930s and 40s
began to change, shifting care delivery to hospitals rather than in people’s own
homes. Thus, prior to and at the time of the inception of the NHS, the role of the
nurse was viewed predominantly as to assist the doctor, obey (his) orders and
14
provide for patients’ personal nutritional needs (Pugh, 1944). In contrast to this,
nurses are now increasingly expected to be autonomous and to challenge doctors
when appropriate (NMC, 2008).
In addition, because of the fundamental changes to the health care system, nurses’
roles have become increasingly diverse (Storch et al., 2004). Nurses are now
required to manage complex nursing interventions, some of which had previously
been undertaken by medical staff (Torjuul and Sørlie, 2006). Nurses are becoming
autonomous, independent practitioners and, as a result, are faced with increasingly
complex decisions which require sensitivity, moral reasoning and clear, justifiable,
ethical decision-making (Storch et al., 2004). These changes in the nurse’s role
coincided with the move of nurse education into Higher Education institutions,
commencing with Project 2000 (Ramprogus, 1995) and, .more recently, the move to
an all graduate profession (NMC, 2004; 2010a).
The move to an all graduate profession recognises that importance be placed on the
nurse’s ability to think critically (Standing, 2011). Critical analysis of the situation and
critical thinking are required in order to make appropriate decisions about patient
care, service delivery and organisational policies and procedures (Standing, 2011).
The current position requires nurses to meet the needs of patients and the
expectations of patients’ families and to work in line with evidence-based practice
and government policy, ensuring that high quality care is delivered within current
resource levels (Jenkin and Millward, 2006). It is suggested here that it is these
competing demands that result in complex ethical decisions, which registered nurses
are expected to address effectively, not only by the public and the organisation but
15
also by their professional body. Investigation into incidences where care has broken
down and standards of care have fallen below the standards expected by patients
and their relatives and those set for the NHS has resulted in nursing being
scrutinised and the Chief Nursing Officer for England, Jane Cummings, calling for
nurses to be caring, compassionate, competent, courageous, to communicate
effectively and be committed to foster a service with compassion at the centre
(Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser, 2012).
The adoption of these ‘6 Cs’ indicates that personal characteristics are once again
viewed by patients and policy makers as important when selecting individuals for
nurse training and that their importance is equal to that of knowledge and clinical
skills in the perception of a “good” nurse. The moral character of the nurse has
never, in recent times, been more scrutinised.
1.2 Background: Ethical decision making in nursing
Definitions of nursing identify the importance of ethical values and the professional
relationships nurses have with patients and other health care professionals (Royal
College of Nursing, 2003). Within the UK nursing is bound by its Code of Conduct
(NMC, 2008), in which nurses are accountable for their actions and therefore need to
be able to justify their decisions. Seedhouse (1998), amongst others, has suggested
that nurses’ accountability may be viewed as a moral venture and, therefore, morally
special. This suggests that those who choose to work for health care pledge to a
powerful set of moral obligations.
16
The terms “ethics” and “morals” are used interchangeably by some authors (Singer,
1993; Banks and Gallagher, 2009). Clear distinction between moral reasoning and
ethical decision making is made by Seedhouse (1998) who refers to moral reasoning
and ethical action. Hawley (2007) describes ethics as the study of moral behaviour
and moral behaviour as that which is good or bad, right or wrong; almost the
opposite to Seedhouse (1998). Others also make a distinction between morals and
ethics, suggesting that ethical action is underpinned by moral values (Tong, 1997;
Johnstone, 1999; Fry and Johnstone, 2002).
Whilst acknowledging this divergence of views within the literature, the theoretical
framework in Section 1.3 presents moral reasoning and ethical decision making as
distinctly different and as the first two stages of a three stage model. The term moral
reasoning is used to refer to the reasoning that is undertaken based on personal and
professional beliefs and values. Ethical decision making refers to the aspects of the
decision making that can be seen to be underpinned by ethical principles and
theories. The final third stage of the framework is moral action; this is the behaviour
and actions, informed by both moral reasoning and ethical decision making,
undertaken by the nurse. All cultural groups have a set of moral values and beliefs
which influence their choices and behaviour; these choices and behaviours are
subject to ongoing revision and refinement (Carter and Klugman, 2001; Banks and
Gallagher, 2009). Ethics is viewed as the reflective process within which this group's
choices, based upon their values and beliefs, are systematically appraised using
ethical principles and rules (Carter and Klugman, 2001).
17
Harris (1985) has suggested that it is through concern and care for others, including
efforts which people are willing to make in providing care, that the value placed upon
their lives and the respect for them as individuals is demonstrated. Where
differences occur in the ability or willingness to provide care, or the failure to meet
the expectations of those involved occurs, a dilemma may arise (Seedhouse, 1998).
Harris (1985) further states that nurses need to address these ethical dilemmas,
claiming that judgments are based on beliefs and values and, whilst the decisions
made to resolve ethical dilemmas are often examined, rarely are the beliefs and
values underpinning the decision examined in the same way.
Within current health care practice ethical dilemmas [which are defined in Section
1.3a] not only occur when the nurse is faced with extraordinary situations but, more
commonly, in day to day practice, which includes challenging decisions regarding
new treatment options and the appropriateness of treatment (Storch et al., 2004).
The increasing number of complex and expensive options at the disposal of health
care professionals, resulting from technical developments, has increased the
frequency and emphasis of these decisions (Bunch, 2002; Aroskar et al., 2004;
Storch et al., 2004; Hugman, 2005).
There is a requirement placed on the health care team to consider the person at the
centre of care provided, whilst considering broader issues associated with the
availability of resources within organisational and political objectives (Padgett, 1998;
Chambliss, 1996; Storch et al., 2004). As members of the health care team nurses
need to behave in an ethical manner, considering the professional relationships they
build with others in the course of their nursing practice (Chadwick and Tadd, 1992).
18
The nurse-patient relationship, as defined in The Code: Standards of conduct,
performance and ethics for nurses and midwives (NMC, 2008), places an obligation
on the UK nurse to act as advocate and to do what is best for the patient. This
obligation in itself may result in conflict, as what the patient believes is ’best’ and in
line with his or her wishes may conflict with the opinions of others (Fry and
Johnstone, 2002). Johnson (1997) identified how the imbalance of power between
nurses and patients can result in patients having to conform to treatment regimens.
In addition, in order for the nurse to undertake the role of patient advocate
effectively, the relationships nurses have with other health care professionals and
patients’ relatives are vitally important (Hawley, 2007).
Professional relationships between nurses and doctors have undergone significant
change over the past 20 years, with nurses increasingly involved in decision making,
managing care and delegation of parts of that care (DH, 2011). This brings both
opportunities and challenges and, with the publication of Modernising Nursing
Careers by the Department of Health in 2011, a number of initiatives were introduced
including a ‘Nurse Leadership’ initiative, the ‘Flying Start’ programme improving
preceptorship for newly qualified nurses. New nursing roles include specialist
nurses, consultant nurses and nurse practitioners, who now make decisions about
treatments which may have previously been addressed by the doctor whose care the
patient was deemed to be under. The changes in these roles have occurred in
response to the needs of those accessing health and social care services,
underpinned by government policy (DH, 2000; 2006; Darzi, 2008).
19
Judgement and decision making are also important aspects of nursing practice, as is
the resolution of ethical dilemmas which requires the ability to weigh the options in
order to identify the appropriate course of action (Thompson and Downing, 2002).
Evidence based practice (EBP) has become an important part of clinical decision-
making; however, it can be argued that EBP alone fails to recognise the values of
the patients and their families in the decision making process. This is particularly
important when promoting patient autonomy and in recognising the unique nature of
each person, their diagnosis and the potential for intervention (Martin, 2004). It is
important, therefore, when making clinical decisions, that moral reasoning and
ethical decision making are included rather than relying entirely on science (Martin,
2004).
Ethical decision making in nursing practice has been informed and underpinned by
medical and bio-ethical approaches (Chambliss, 1996; Storch et al., 2004). These
are discussed in more detail below. They include deontological and consequential
theories that may be characterised as rule-based or act-centred as well as virtue
ethics and the ethic of care, which have been advocated within nursing practice and
nurse education and may be considered to reflect a more person oriented, agent
centred approach (Johnson, 1997; Gilligan 1982; Armstrong, 2007).
Gilligan (1982), Johnson (1997) and, more recently, Armstrong (2007) highlight the
limitations of obligation or rule-based approaches to moral reasoning and ethical
decision making in the context of nursing practice, arguing that these approaches
are inadequate in their failure to recognise the importance of emotion in moral
reasoning. The development of an individual nurse’s reasoned decision making and
20
the accomplishment of competence through the various stages of their professional
development are also recognised as important to this decision making process
(Benner, 1984, Carter and Klugman, 2001). However, it is the relationships that
nurses have, as students with their mentors and, later, with a preceptor, that can
influence their development as competent nurses and maintain their ability to care
(Smith, 2012).
1.3 Theoretical framework
Nurses who are required to maintain moral and ethical standards in practice find that
they are increasingly restrained by the clinical and caring environments within which
they work (Redman and Fry, 2000). To participate effectively in working for health
as a moral venture, nurses require moral sensitivity, moral reasoning skills and the
ability to recognise a moral issue in a given situation, which results in the need for
ethical decision making to inform moral action (Harris, 1985; Seedhouse, 1998;
Johnstone, 1999).
This staged approach to decision making is illustrated in the theoretical framework
developed for this study [see Figure 1] which recognises that ethical dilemmas occur
within the context of nursing practice and suggests that it is a person’s moral
conscience that alerts them to the fact that things are not necessarily ‘right’ (Hawley,
2007). It is this moral conscience, informed by the beliefs and values held by the
individual, that informs initial expectations (Hawley, 2007). Moral conscience is also
described as moral sensitivity, which is guided by feelings of compassion, sympathy
and concern of one for another (Storch et al., 2004). However, these authors also
21
argue that moral sensitivity requires cognitive and imaginative skill in order to apply
moral theories to a given situation.
Registered nurses are both accountable for their actions and have an obligation to
advocate for those to whom they have a duty of care (NMC, 2008). In order to meet
these requirements it is suggested, in this theoretical framework, that some or all of
the ethical approaches to decision making, moral action and the resolution of
dilemmas recognised throughout the health care literature may be used to explain
how nurses respond and to justify their actions.
Through systematic searching of the current literature studies and debates were
identified as pertinent to the background and development of the theoretical
framework and are detailed in Appendix 1. Sections 1.3a–d below outline the stages
of this framework.
1.3a Ethical dilemmas
Some research investigating ethical dilemmas fails to present a working definition of
an ethical dilemma, for which there may be valid reasons. [ some authors, , justify
this omission in their published articles (Oberle and Hughes, 2001; Aroskar et al.,
2004; Dierckx de Casterle et al., 2004; Hurst et al., 2005). Authors who do provide
definitions of an ethical dilemma include Beauchamp and Childress (2001) and
Hamric et al., (2000), explaining that an ethical dilemma occurs when a given
situation has two or more conflicting moral principles. This is further developed to
include the recognition that, when addressing the dilemma, the available alternatives
22
appear to be equally undesirable and the correct course of action unclear
(Noureddine, 2001).
In nursing practice ethical dilemmas occur in situations where the beliefs and values
of the patient, their relatives and/or the nurses and the organisational objectives may
conflict in some way (Kain, 2007). This may result in differing expectations which
inform the action taken by the health care team. Storch et al. (2004) identified that
the ethical dilemmas that nurses are required to address within their practice are
becoming distinctly different to those traditionally addressed by physicians in relation
to medical ethical dilemmas. As such, these dilemmas may not be adequately
addressed through the bio-ethical approach traditionally used in medicine (Storch et
al., 2004). This is because the nurse’s role extends beyond the medical perspective
of treatment and cure; nurses are required to meet the full diversity of patient need.
Through the development of holistic relationships (Tschudin, 1999) and providing
person centred care for patients (Kitson, 2004), nurses strive to meet the diversity of
patient needs (Storch et al., 2004). It may be argued that nursing ethics is now
developing as a distinct approach, separate but influenced by medical ethics, to
reflect the different mandates to care held by each profession (Chambliss, 1996;
Storch et al., 2004).
Ethical dilemmas in nursing often arise from the same issues faced by other health
care professionals. The difference is that the engagement the nurse has with the
patient and their family is continuous throughout the episode of poor health which
may have resulted in the dilemma (Chambliss, 1996). This continuous contact
facilitates the development of therapeutic relationships (Kitson, 2004). For nurses,
23
as for other health care professionals, the context in which they work has changed.
Because the role the nurse undertakes, in many cases, is a co-ordinating role for
care provision and forms the link between the patient, the family and other health
care professionals, the nurse often has a unique overview of the issues involved
(Storch et al., 2004).
Ethical dilemmas in health care take many forms. These include the big questions,
for example resuscitation orders (Herbert, 1997); issues around care of the dying,
withdrawal of and/or withholding treatment (Elger and Harding, 2002); the provision
of futile treatment (Hurst et al., 2005; Clará et al., 2006); and organ donation (Bunch,
2002). However, of equal importance are the smaller questions that impact on the
daily work of nurses, such as provision of information, confidentiality and the
disclosure of information to third parties (Jenkin and Millward, 2006). Whilst there is
legislation to guide nursing practice decisions on how to act, this requires careful
consideration in the application of the law; dilemmas in relation to this occur when
the nurse has conflicting duties and responsibilities (Jenkin and Millward, 2006).
In the UK, organisational policy impacts upon the nurse’s ability to make
autonomous decisions in relation to patient care (Torjuul and Sørlie, 2006).
Organisations such as the Department of Health, regional and local Health
Authorities and NHS Foundation Trusts are responsible for the allocation of
resources, which may be challenging when demand outstrips supply within the
current health care system (Oberle and Hughes, 2001). Analysis of organisational
decision-making does not fall directly within the objectives of this study, as this is not
in the UK nurses’ control, however in the United States of America it is a major part
24
of the role of the Utilisation Nurse, whose job it is to make decisions about best value
treatments in relation to patient outcomes (Bell, 2003).
Nurses engage with resource allocation on a daily basis. Nurses have only so many
hours in which to manage, plan and deliver care; ward budgets and availability of
other health care professionals are limited (Torjuul and Sørlie, 2006). The nurse -
patient relationship and the closeness of nurses to the patient group result in a
perceived increased accountability and the duty to meet patients’ needs
appropriately (Torjuul and Sørlie, 2006). In order to achieve this nurse must be able
to prioritise the needs of any patient group and to guide the doctors and other health
and social care professionals as to whose needs should take priority (NMC, 2010a).
All patients are important and the health care professionals providing care and
treatment have to make some tough decisions; these are, for some nurses, everyday
decisions (Storch et al., 2004).
Decisions in an acute situation may need to be made quickly with whatever
information is available at the time; it may be that these decisions are taken more
frequently in secondary care settings rather than in other health care settings. In the
accident and emergency department, in the medical assessment unit, in intensive
care or theatres, or in life threatening situations, the team has only minutes to decide
on a course of action (Farsides, 2007). Not all ethical dilemmas need such urgent
attention; these are, however, equally important. Decisions made in all situations
may have an impact on the patient’s long-term health and wellbeing, however nurses
within health and social care teams may have more time to discuss the situation and
negotiate what needs to be done, encompassing the wishes of the patient and those
25
on whom the outcome may impact, weighing the options available in partnership
(Farsides, 2007).
1.3b Moral reasoning
Moral problems and moral dilemmas are those which engage our beliefs and values
about what is fundamentally right or wrong, good or bad (Hawley, 2007). Diversity of
opinion, it has been suggested, through freedom of thought, helps the development
of moral character, resulting in self-determination (John Stuart Mill 1806–1873).
Self-determination allows each person to make their own decisions about their own
life style, with whom they associate and how they pass their time. Nurses may
experience moral distress when their self-determination is compromised because
they feel they are unable to maintain their personal or professional moral ideals and,
consequently, their professional integrity (Torjuul and Sørlie, 2006). This is
apparent, for example, when nurses are not able to ‘tell the truth’, as they might see
it, to the patient in their care, for example not providing full information about
diagnosis, prognosis and/or treatment (Torjuul and Sørlie, 2006). Caring and
upholding standards of care appear to be important aspects of nursing and reflect
the professional values nurses hold; when this is compromised nurses may begin to
feel dissatisfied with the situation (Torjuul and Sørlie, 2006). Further research, of
nurses working within the hospice setting, goes on to suggest that maintenance of
human dignity is an important moral obligation in their practice (Salloch and
Breitsamater, 2010). These nurses strive to be non-judgmental and recognise the
need to respect the wishes of the patient in their care even if this is in direct conflict
with their professional judgement (Salloch and Breitsamater, 2010).
26
What may also be of importance when researching ethical decision making in
nursing is that it is a predominately female profession, with 89.29% of those currently
registered on the Nursing and Midwifery Council’s register being women (NMC,
2010b). The percentage of male registrants has remained constant since 2004
(NMC, 2010b). It may be that gendered traits also dominate the nurses’ moral
reasoning which is used to inform nursing practice.
Gilligan’s (1982) seminal work on the gendered nature of moral reasoning
demonstrated that girls were inclined to articulate their reasoning in ways that were
different from boys. Boys were more likely to display thinking that correlated with
Kohlberg’s1 (2008) ‘classical’ stages of development, speaking in what Gilligan refers
to as ‘a different voice’. She argued that theorists such as Kohlberg developed their
ideas through observations of men and their ways of reasoning, failing to take into
account the gendered nature of such research. Male development has thus been
taken to be ‘normal’ and generalisable, making the reasoning displayed by woman
participants appear to be less well developed. Further, Noddings (2003) suggests
that it is women’s moral development that informs an act-centred approach to ethics
that may be seen in the ethics of care and in virtue ethics, which are discussed
below.
The nature of nursing and the job itself may also impact on nurses’ attitudes and
their moral views, perhaps influenced by the position of nurses within the health care
team and the work they undertake; thus the gendered nature of nursing’s
professional identity, rather than the actual gender of individual nurses.. The two
1 Kohlberg first developed this theory as his PhD dissertation in 1958 and continued to publish on it throughout
his academic career.
27
may be intractably entwined because of the constantly high proportion of nurses who
are women; however this may be impossible to confirm (Chambliss, 1996).
Moral reasoning is also influenced by the values, beliefs and expectations of an
individual’s parents, religion and peers as they grow up; these may change
according to our life experiences (Cuthbert and Quallington, 2008). Values and
beliefs inform moral conscience, which helps in the recognition of the moral quality of
behaviour, thus informing actions. Amongst these influences are those of the
profession into which nurses become socialised and the experiences encountered as
part of nursing practice (Benner, 1984; Settelmair and Nigam, 2007). Taken
together these values can be seen to inform the nursing code of professional
conduct: The Code (NMC, 2008).
In summary, moral reasoning is influenced by personal beliefs and values, gender,
socialisation and professionalisation. Values may become revised and refined over
time and through experience (Carter and Klugman, 2001). Challenges to a nurse’s
moral reasoning may occur when there is a conflict between patients and their family
or the health care team when addressing moral issues (Salloch and Breitsamater,
2010), leading to the need for ethical decision making.
1.3c Ethical decision making
Ethical decision making is framed within a number of recognised ethical approaches
which are described below and which are the third stage of the theoretical
framework.
28
The four approaches outlined are often characterised as either principle-based [non-
feminist] or agent-centred [feminist] in nature. Principle-based approaches have
tended to dominate health care ethics, however agent-centred approaches, have
enjoyed an increase in popularity amongst such authors as Tong (1998), Storch et
al., (2004) and Armstrong (2007).
Whilst ethical approaches fall primarily into these two groups some authors
recommend a pluralistic combination of approaches, thus bringing the best from
each according to the situation (Botes, 2000a). In practice, as will be seen in the
findings of this thesis, all four approaches, or elements of each, may be drawn upon.
Hence they are represented, in Figure 1, as equally important.
Principle Ethics These approaches are predominately underpinned by the work of
the classical philosophers Immanuel Kant (1724–1804) and William David Ross
(1877–1971); these deontological approaches use the language of duty, of what a
person ought or ought not to do. David Hume (1711-1776) , Jeremy Bentham (1748
–1832) and John Stuart Mill (1806–1873) developed consequentialist approaches
which consider the consequences of the action to be central to decision making,
balancing both the benefits and the burdens of that action to inform decision making
(Cahn and Markie, 2006).
It can be argued that both deontological and consequential approaches lead to
principles, a method that has gained popularity amongst medicine and then nursing
as a way to support ethical decision-making in professional practice. The principles
applied are those of autonomy, beneficence, non-maleficence and justice
29
(Beauchamp and Childress, 2001). The principles approach is underpinned by
western moral philosophy, which consists of the four principles above and ethical
rules of confidentiality and veracity (Hawley, 2007). Philosophy provides both meta-
ethics and normative ethics. Meta ethics consider the meaning of moral language;
normative ethics are those which are here to provide ethical theory to guide
decisions and behaviour (Beauchamp and Childress, 2001).
Deontology encompasses ethical approaches to examine what we ought to do in
relation to a given situation. Within these approaches the aim is to consider
decisions and actions as if they were universal laws which would apply in any given
situation. Such ethics can be seen in religious doctrine, such as the Koran or the ten
commandments of the Old Testament. They also underpin professional codes of
practice. However, the most recognised theory is Kant’s (see Cahn and Markie,
2006, p. 270). Kant provides guidance on how we should act:
1. In a way that we would always act - resulting in ‘universal law’,
2. Treating each person as an end in themselves, not a means to an end,
offering respect to all people with dignity.
He argues that these ‘laws’ inform us of what ought to happen and how to make
ethically rational decisions.
However, applying these laws universally has limitations, for example deciding which
law or rule should take priority and whose rights to prioritise in any given situation.
The basis or fundamental principle of Kant’s approach indicates that no one
(including oneself) should be treated simply as a means to an end but as an end in
themselves. This fundamental principle or law provides a system of duties to oneself
30
and others. These duties are referred to as perfect duties and imperfect duties.
Perfect duties are actions which must always be observed; there are no exceptions
to these rules. These actions, also known as negative obligations, require the actor
(in the case of nursing practice this is the nurse) to desist or refrain from an action.
Imperfect duties are actions which are positive obligations and require that the actor
(nurse) act or behave in a certain way. It is the intention with which actions are
performed that is central to this approach, rather than the consequences
(Beauchamp and Childress, 2001).
Whist deontological approaches have dominated medical and health care ethics for
some years nursing ethicists argue that, due to their rigid nature, they to some extent
fall short of meeting the dilemmas faced by nurses in the current context of nursing
practice (Johnson, 1997; Armstrong, 2007). However, Dierckx de Casterle et al.
(2004) may support the view that rule based ethical approaches still have a place in
nursing decision making. Their empirical work revealed that nurses relied on the
convention of practice: rules of the organisation, expectations of the patient’s family
and colleagues and procedures learned during their education, rather than being
reflective in nature. Their findings suggest that nurses struggle to engage effectively
in ethical practice as they do not appropriately consider the patient’s personal needs.
Consequentialist theories focus on the outcome of an action to judge whether or
not a particular course of action is ethical in nature. Utilitarian theories are probably
the best-known of this group of theories. These indicate that each person should
strive to promote ‘the greatest good for the greatest number’ in order to maximise the
‘utility’, or outcomes of a situation when making the decision to act. Philosophers
31
David Hume, Jeremy Bentham and John Stuart Mill developed the idea of the two
extremes, pain and pleasure, to demonstrate the principle of utility (Cahn and
Markie, 2006). These theories determine the moral rightness of actions based on
the balance of the good and bad consequences of those actions (Fry and Johnstone,
2002).
The main aim is to consider which action will result in the most happiness; the main
criticism is that those in minority groups may be disadvantaged (Tong, 1997). In the
provision of health care ‘cost benefit analysis’ is used to analyse expenditure
(Hawley, 2007), encouraging health care professionals and organisations to
maximise the use of resources available. However, this approach could lead to
expensive treatments not being funded in favour of less expensive treatments,
resulting in a greater number of people receiving care but perhaps limiting funding
being allocated for research and treatment of rare conditions from which only a few
will benefit (Beauchamp and Childress, 2001).
Despite the limitations of this approach it remains important, as health services are
experiencing increased demand as people live longer and the ability to treat more
conditions in more complex ways continues to increase (Bunch, 2002; Aroskar et al.,
2004; Storch et al., 2004; Hugman, 2005). Policy making bodies such as the
National Institute for Health and Clinical Excellence, NHS England, other
commissioning groups with responsibilities for commissioning services and executive
board members may find consequential approaches most effective when discussing
and planning service provision. For some time the formulas used for the allocation
of health services have included Quality Adjusted Life Years (QALYS), which
32
examines the potential outcome of a treatment (Allmark, 1998). Nurses may be
involved in policy development; this is dependent on their role. Nurses working in
secondary care are, however, in the position of making decisions associated with the
distribution of resources on a daily basis as they work within the context of limited
resources (Kalvemark et al., 2004). This approach also encourages health care
professionals to consider the patient’s feelings of ‘pain and pleasure’ on an individual
basis and, as such, may help in identifying the most appropriate course of treatment
or care for individual patients.
Whilst deontology and consequentialism have clear differences, what they have in
common, Singer (1993) suggests, is more important; when addressing ethical
decisions or judgements ethics should support a universal viewpoint. Not simply that
the principle should be applied universally but that the context or situation influences
the application of that principle and should move beyond individual likes and
dislikes to ensure an impartial standpoint.
Beauchamp and Childress (2001) argue that the principles of autonomy, justice,
beneficence and non-maleficence can be justified from both approaches, giving a
basis for decision making in health care ethics. In addition, Botes (2000b) views
deontological and utilitarian approaches as opposite ends of the same spectrum and
calls for compromise in order that a satisfactory resolution be found for complex
ethical dilemmas, recommending a combined approach.
Agent Centred approaches may be seen as a counter position to the principle
based theories above. In their most recent edition, Beauchamp and Childress (2013)
33
use an overarching term, ‘moral character’, to bring together theories related to
moral virtue (see below) as associated with the work of Aristotle (384BC–322BC)
and more recent work on the ethics of care (Gilligan, 1982). These approaches are
located in practice and often seek to find middle ground or compromise between
extremes. Thus the focus of agent approaches goes beyond the action, requiring the
agent (in this case the nurse) to consider ‘how should I be’ rather than simply ‘what
should I do’. The emphasis, therefore, is on the behaviour of the nurse in a given
situation. This approach has the potential to facilitate moral learning and
development such that, through a mix of emotion and reason, the nurse can develop
competence in this aspect of professional practice (Hawley, 2007).
Virtue ethics: Aristotelian virtue ethics has been significantly developed in recent
decades, notably by authors such as Hursthouse (1999). Within nursing, Armstrong
(2007) provides a strong argument in defence of a virtue based approach,
highlighting the importance of the therapeutic relationship between patient and
nurse. His work, alongside that of Banks and Gallagher (2009) and Sellman (2011),
represents a significant development of virtue theory related directly to caring
professions such as nursing and social work. The nurse, it is suggested, needs the
following qualities: trustworthiness, honesty, kindness and patience. Virtue based
ethics may be akin to moral virtues and moral reasoning in their recognition of the
qualities the individual brings to the situation rather than the objective principles of
duty based approaches. Virtue based ethics are concerned less with right action
and more with the way we act: kindly, justly, patiently; recognising the importance of
moral character, the significance of interpersonal relationships and the importance
that emotions have in moral life. Most importantly they acknowledge that ethical
34
dilemmas are not always solvable. Banks and Gallagher (2009) develop Aristotle’s
overarching ‘practical wisdom’ into ‘professional wisdom’ as the central virtue that
guides professionals to good choices. However, Armstrong (2007) acknowledges
that that virtue based ethics may fail to provide guidance for action and how to
address conflicts between virtues.
It is in virtue ethics that the divide between the genders may become more apparent.
Tong (1998) suggests that some philosophers argue that men and women possess
the same moral virtue but that women are more emotionally focused and aware of
their feelings than men and that men are more likely to engage in a reasoned
approach, as proposed within act-centred approaches to ethical decision making.
Others, however, argue that the differences are cultural and as society did not permit
or encourage women to develop reasoning and express opinion, women therefore
became governed by emotion (Tong, 1998).
Within virtue ethics the agent is required to have the cognitive skills to see what is
good and right in order to act in the morally right way. The agent and the act are
viewed as inseparable, a complete contrast to the consequentialist approach (Tong,
1998).
Aristotle believed that an individual cannot undertake a caring act for someone
unless that individual actually cares, that is, they are a caring person. A person who
really cares will feel something for the objects of that care; in the case of nurses this
will primarily be the patients in their care and may also extend to the patient’s family
or colleagues within the nursing, health and social care team (Blum, 1988).
35
Ethic of care: Beauchamp and Childress (2013) suggest that, for some theorists,
‘care’ is a virtue; however, the term ‘ethics of care’ is usually attributed to the work of
Gilligan (1982). In her attempt to define the gendered voice she heard in her
research she used the phrase ‘ethics of care’ to define decision making that was
different from justice, principles or rules. Thus it is strongly associated with agent-
centred ethical theory. It may be viewed as a virtue ethic of a specific nature; the
action and the actor being judged as one. Only a morally good character is capable
of a morally good act (Hawley, 2007).
The Ethic of Care, also underpinned by the work of Noddings (2003), focuses on the
attention and care given to others and the relationships nurses and health care
professionals build with patients and their families. Allmark (1998) highlights the fact
that everyone cares but the key is what people care about and how they care about
it. This focus makes it a morally good act, challenging the idea that caring is a virtue
in its own right and supporting the importance of the right actor and the right act.
The health care professionals’ mandate to care and the emotions of caring are
central characteristics of this approach (Hawley, 2007) indicating that, in order to
care and undertake caring, the actor (in this case the nurse) must really care and
feel the desire to care. This is in contrast to principled approaches which expect
universal principles to be applied using reason alone. The nurse-patient relationship
is distinctly different to the caring relationship between a mother and her child. Both
these caring relationships depend on trust; the nurse-patient relationship is a
36
professional caring relationship and ethical caring, and requires both effort and
attention (Noddings, 2003; Hugman, 2005).
1.3d Moral action
Within this theoretical framework the final stage, moral action, is informed by a
process of moral reasoning and ethical decision making. This action may be in
partnership with others; patients, their families and other health and social care
professionals, because nurses work within multidisciplinary or interprofessional
teams (NMC, 2004; Torp and Thomas, 2007; NMC, 2008). It is important to
remember the debate surrounding the exact nature of a truly moral act. The
question is whether an act is truly morally correct if it is simply duty motivated by
what ought to be done or undertaken for personal gain. Beauchamp and Childress
(2001) argue that moral virtue is a disposition to act in accordance with moral
principles, suggesting that if a person performs a morally right action but his motive
is improper then a moral ingredient is missing. This would indicate that resulting
‘moral’ action taken by the nurse or health care team is truly moral only when the
motive is proper. The right action may, however, be undertaken because it is what
ought to be done rather than what the nurse wants to do. The act is undertaken
because it is required by law or by a contract of employment.
1.4 Summary
This introductory chapter has located the thesis within the context of resolving the
ethical dilemmas nurses face in secondary health care in the UK. It has outlined a
theoretical framework, based on ethical dilemmas leading to moral reasoning, which
informs ethical decision making and leads to moral action. This framework was used
37
to guide the development of the research plan and its use is critically explored in the
discussion of the research findings.
38
Figure 1: Theoretical framework: Resolution of ethical dilemmas in nursing practice
Moral action and resolution
Ethical decision making
Deontology Consequentialism Virtue ethics Ethic of care
Moral reasoning
Beliefs Values Expectations
Ethical Dilemma
Two or more conflicting courses of action
39
Chapter 2 - Literature review
2.0 Literature review
Having outlined the focus of the thesis and the theoretical framework in Chapter 1,
this chapter presents an integrative review of related literature including
philosophical discussion, literature reviews and empirical studies. The aim of the
review is to better understand current thinking on nurses’ ethical decision making in
order to clarify and refine the aim and objectives of this research.
Peer reviewed journal articles make up the main source of materials used in this
literature review. These are considered to be a robust source of evidence, reviewed
by two or more experts in the field with a lead time which is significantly shorter than
that required when publishing books (MacNee and McCabe, 2008). Care has been
taken to include recent material, published within the last ten years, to ensure that
the evidence is relevant to the context within which nursing is currently practiced.
Grey literature was searched using the EThOs database which provided access to
recent Doctoral theses through the British Library. Grey literature also includes
unpublished work such as conference proceedings, which may provide a good
source of materials when performing a literature review (Parahoo, 2006).
2.1 Search Strategy
Through systematic searching of the literature the following studies and current
debates were identified as pertinent for literature review; the search structure is
detailed in Appendix 2.
40
2.1a Database selection
Electronic database searches were performed using the databases CINAHL
(cumulative index nursing and other health related professions), ScienceDirect,
Medline, Psychinfo, Web of Science and British Nursing Index, which provide access
to peer reviewed, published material relevant to the subject (Fink, 2009). This
combination of databases provides access to most English language nursing
periodicals, standards of practice, government publications, research instruments
and patient education material (Blackwell Synergy, 2011; CINAHL, 2011; Science
Direct, 2011). During the final stages and writing up of the thesis previous searches
were updated to capture any work published in the interim period.
Limits were set to ensure focused searches were undertaken to avoid
unmanageable amounts of material being included in the search returns. Limits
were also set to identify relevant literature for abstract review to facilitate selection
for inclusion within the review process (Robson, 2002).
The limits set were:
Written in English
Peer reviewed
2000 – present
Original articles.
A range of key words and synonyms were used for each section of the search; these
were Nursing and:
Moral reasoning / Moral issues/ Moral dilemmas
Ethical reasoning / Ethical issues / Ethical dilemmas
41
Moral / Ethical approaches
Moral / Ethical Action.
Moral / Ethical professional codes
Further journal searches were undertaken in the journals; Nursing Philosophy and
Nursing Ethics.
Using a combination of abstract review and critical appraisal, articles were selected
for use within this review (See Appendix 2).
2.1b Record keeping
Cataloguing and storage of data are essential to avoid error and duplication. All
articles were carefully catalogued, entering full reference source and search strategy
on to the cataloguing system. Both electronic and manual index card methods are
available (Hart, 2005). A simple electronic system was mirrored by a paper file of
reviewed articles, stored according to a search code. A total of 27 papers were
retained for discussion within the literature review.
2.2 Critique
Once identified as having the potential to be included in the final literature review, it
is important to critically read the full article to establish its quality and relevance (Polit
and Beck, 2008). Comparability is an important aspect of the literature review
process; articles selected must be read with purpose, in an organised manner, which
will facilitate comparison of the content and the quality of the evidence (Fain, 1999;
Parahoo, 2006; Cutcliffe and Ward, 2007; Polit and Beck, 2008).
42
Systematic recording of specific areas for consideration within the review were
identified and an evaluation pro-forma generated for recording the analysis (see
Appendix 2). The pro-forma used to facilitate comparability was based on Burns and
Grove’s (1987) model and Morrison’s (1991) model; adaptations have been
developed to accommodate the different types of literature within this review (see
Appendix 3). The critique has been approached with some level of flexibility in order
to facilitate this.
As each article was reviewed, notes were made on the evaluation pro-forma,
drawing together aspects of each piece of literature. This could then be referred to at
any time whilst writing up the literature review.
2.3 Results
A number of themes emerged from the literature reviewed which helped to identify
what is already known about the contribution made by nurses in addressing ethical
dilemmas in practice and to expose gaps. These themes were:
a. Codes of ethics
b. Policy
c. Moral distress
d. Conflict and collaboration within ethical decision making
2.3a Ethical codes
Functions of professional ethical codes include providing a vehicle for expressing the
values of the professional group and guidance for decision-making and behaviour for
those within the professional group (Verpeet et al., 2004). Nursing professional
43
codes exist at international and national levels. They provide nurses with a code of
conduct; codes inform nurses how they should act, safeguarding the profession’s
reputation and, more importantly, protecting service users (Banks, 2003). Nurses in
Britain have the Nursing and Midwifery Code of Conduct (The Code, NMC, 2008).
Like other codes this comprises the rules of the profession, statements that reflect
the character that nurses should possess, ethical principles and rules (Banks, 2003;
NMC, 2008).
The Code (NMC 2008) is the primary source of guidance for nurses registered to
practise within the UK and is intended to guide nurses’ decision making and
behaviour. Key aspects include:
‘The people in your care must be able to trust you with their health and wellbeing’
(page 2).
‘Make the care of people your first concern, treating them as individuals and
respecting their dignity’ (page 3).
‘Work with others to protect and promote the health and wellbeing of those in your
care, their families and carers, and the wider community’ (page 5).
‘Provide a high standard of practice and care at all times’ (page 6).
‘Be open and honest, act with integrity and uphold the reputation of your profession’
(page 7).
Each aspect of The Code (NMC, 2008) is developed further and guidance is
available to support the application of The Tinto nursing practice. The Code, along
with other nursing codes of ethics, provides nurses with a professional identity,
support for nursing, guidance and motivation (Verpeet et al., 2004).
44
Each country has its own code with an overarching code provided by the
International Council of Nurses (ICN) which was first established in 1953 (ICN,
2012). The ICN Code guides nurses in a number of areas, including nurses and
people, nurses and practice and nurses and co-workers (ICN, 2012). Like the NMC
Code (NMC, 2008) guidance is provided on the implementation of the ICN Code and
each of these main sections is broken down to provide further detailed guidance to
nurses. The ICN clearly states that the code of ethics is based on social values and
provided as a guide for nurses’ actions, thus suggesting shared values that nursing
might have regardless of cultural, racial or national boundaries. The ICN code of
ethics has influenced the nursing ethical codes of a number of countries in Europe,
including Greece, Finland and Italy (Heikkinen et al., 2006).
Nurses’ codes of ethics are regularly updated to reflect social values and changes in
the context of nursing practice and nurses’ roles (NMC, 2008; ICN, 2012). It is,
however, very clear that a primary consideration, found at the core of all nursing
codes, is the best interests of the individual. In the UK the NMC Code (NMC, 2008)
is frequently reviewed and developed by the Nursing and Midwifery Council in which
nurses are directly involved. There is also a period of consultation where all
registered nurses are given the opportunity to comment and provide feedback on a
draft version of The Code prior to a final version being adopted (NMC, 2010c).
Despite this unity, one criticism of codes of ethics is that they often contain vague
statements rather than clear guidance (Lere and Gaumnitz, 2003). An exploration
undertaken amongst the business community found that codes of ethics had little
45
impact on the decision making process and that the same decisions would have
been made in the absence of a code. Reasons for this were discussed within Lere
and Gaumnitz’s (2003) focus groups, included the feeling that codes of ethics were
common sense and participants felt they knew the difference between a right and a
wrong action. Thus, they argue that whilst a code should influence actions, it may
not do so unless individuals’ beliefs can be changed or there are deterrents to acting
outside of the code.
Whilst criticised by Lere and Gaumnitz (2003) for being too vague, oppositions to
ethical codes highlighted by Banks (2003) state that using a detailed professional
code may result in the practitioner becoming dependant on the code rather than
making reasoned decisions and, consequently, may risk promoting moral
insensitivity. Banks (2003) goes on to suggest that the general principles currently
contained in these codes can only guide rather than direct and, therefore, the
practitioner still needs to engage in thoughtful application of the principles it contains.
Conducting 23 focus groups, Heikkinen et al. (2006) were able to discuss the
opinions of nurses from three countries about the usefulness of codes of ethics. The
countries involved were Greece, where nursing is still viewed as a low status
profession with limited autonomous decision-making; Finland, where women and
nurses have a history of autonomous decision making; and Italy, where nursing has
undergone changes within the last ten years to a position of more autonomous
decision making within health care. Each country has its own culture and nursing
history and it was possible to discover how these impacted on the nurses’ views of
ethical codes. They concluded that the conscious use of ethical codes was identified
46
as useful in clarifying ethical aspects of nursing and prompting nurses to think
carefully about their decisions and the moral weight of their actions. The nurses
viewed ethical codes as a moral guide, being effective when reflecting on ethical
decisions. Conversely, the research suggested that codes were not directly referred
to in situations where nurses had internalised the values and so implemented them
unconsciously in their work.
Obstacles to implementing professional codes of ethics included the codes
themselves, as they were viewed as abstract and generally failing to provide clear
guidance (Lere and Gaumnitz, 2003; Heikkinen et al., 2006). Collaborative working,
where the views and values of others - the organisation, other health care
professionals, the patients and their families and health care policy - differ from those
reflected in the ethical code, also proved problematic (Heikkinen et al., 2006).
Conversely, Verpeet et al. (2004) identified, through analysing data collected during
a series of focus groups, how ethical codes provide guidance regarding nurses’
relationships with others, with patients, patients’ families, other health care
professionals, society in general and with each other.
The impact of the local culture, women’s and nurses’ status in society was seen in
Heikkinen, et al.’s (2006) study to have an impact on nurses’ ability to work ethically.
This was also demonstrated by Donker and Andrew’s (2011) study involving nurses
working in Ghana. This study involved 200 registered nurses who identified times
when they disagreed with decisions made by the health care team. Instances were
noted where the ICN code of ethics was in conflict with cultural beliefs and norms.
Aspects of care in this regard included patient autonomy, confidentiality, nurses and
47
co- workers and truth telling. In all of these cases it was identified that some of the
Ghanaian nurses felt that it was right that these cultural and social norms should
override the ICN code of ethics (Donker and Andrew, 2011). In another study
exploring ethical codes of practice the issue was less concerned with cultural
‘overides’, but with actual awareness and knowledge of the code itself. Verpeet et
al. (2004) found that some nurses’ knowledge of professional codes was limited and
not used appropriately to inform ethical decision making. Belgian nurses, in their
research, felt it was essential for nurses to be involved in developing ethical codes
and that these should contain guidance for nurses’ behaviour, moral practice,
professional practice and function.
It has been established that nurses use codes of ethics and professional conduct to
inform decision making and where there may be errors of judgment or poor
standards of care, these codes may be used to judge nurses’ conduct (Verpeet et
al., 2004; Heikkinen et al., 2006). The NMC views its primary role as safeguarding
the public; the Code forms part of that mechanism (NMC, 2010c). On balance, it
appears that codes of ethics have an important role to play, however their usefulness
as a sole guide to ethical decision making and the resolution of ethical dilemmas
may be limited. Further, they may not be the primary source of guidance to nurses
in practice.
2.3b Policy
Whereas professional codes of practice guide the behaviour of the individual, policy
is applicable to all people within its remit. Colebatch (2009) states that National
Health Policy is designed and developed by government to provide structure, goals
48
and guidance for health care providers, organisations and individual practitioners.
Under this umbrella, local organisational policy, informed by Health Policy, provides
structure at a local level, the aim of which is to ensure safe practice and direct the
use of scarce resources to meet various government targets. Colebatch goes on to
suggest that the development of health care policy can be difficult as it attempts to
bring together the views of diverse groups of people to develop shared goals, for
example, government, services users, organisational strategic objectives and health
care practitioners, with all their various philosophies.
Whilst reviewing the literature retained for use here it appears to be that policy,
national and local, is viewed as restrictive by nurses providing direct nursing care to
patients. This is because it limits the care they are able to provide and, in some
cases, is in opposition to their personal and professional values and understanding
of what is in the patient’s best interests or are the patient’s wishes (Aroskar, et al.,
2004). Nurse participants in Aroskar et al.’s study took part in a series of focus
groups where they identified how national policy influenced organisational policy,
which had resulted in reduced resources and was felt by them to compromise care.
The nurse participants discussed issues associated with the funding of health care
within the American system, suggesting that decisions about care were influenced by
what was paid for rather than by the patients’ needs (Aroskar, et al., 2004).
Therefore, the level of health insurance patients have has a real impact on the care
delivered. Whilst this is not the case in Britain, for nurses working in National Health
Service hospitals, British nurses also recognised the impact of limited resources,
especially staffing shortages, on patient care, resulting in them feeling angry,
49
frustrated and guilty and, consequently, experiencing moral distress (Oberle and
Hughes, 2001; Corley, 2002).
For some nurse participants in Aroskar et al.’s (2004) study, the increase in available
treatments and the focus on technical intervention rather than that described by
participants as the ‘ethic of care’, may potentially impact negatively on the patient’s
experience. The nurse participants in this and other studies reviewed demonstrated
the value they placed on comforting and supporting patients and families through the
development of meaningful relationships built using effective communication, which
requires nursing time and commitment (Oberle and Hughes, 2001; Aroskar, et al.,
2004; Torjuul and Sørlie, 2006).
It is clear from the literature that national and local policies can impact both directly
and indirectly on patient care. They have the potential to impact on ethical decision
making and the ability to deliver what may be considered to be a good standard of
appropriate care. In addition, Aroskar et al. (2004) identified that policy was
particularly important in ethical decision making amongst executives and nurse
administrators. Decision making was predominately related to careful allocation of
scarce resources and the development of policies to ensure appropriate allocation of
nursing staff. The maintenance of safe staffing levels, promoting fairness by
balancing patient needs whilst respecting patient choice and promoting patient
autonomy, were major challenges for nurse managers in their work and are explored
further in this thesis.
50
Limited resources and the allocation of those resources have been described as
causing ethical dilemmas for nurses because this results in an inability to provide
good quality patient care (Oberle and Hughes, 2001). Nurses in Torjuul and Sørlie’s
(2006) study explained that they felt they should be everywhere at the same time
and were often called away to attend to another task before completing the one that
had already been undertaken. Time spent with patients who had minor problems
detracted from care required by those who were seriously ill; the general feeling was
that limited resources and increased demands on nurses’ time in the face of
changing roles had impacted negatively on standards of care. Policy was a
significant factor in determining how the nurses spent their time; the participants felt
that it was important that when people are admitted to hospital, nurses should be
there for them and their families. Therefore, prioritising who received resources in
terms of nursing time and care routinely presented ethical dilemmas for nurses.
Participants also experienced challenges in maintaining patient dignity and
confidentiality when patients were nursed in shared rooms; during ward rounds,
during handovers and discussing patients’ conditions and private lives. Finally,
concern was expressed that patients might not discuss important confidential issues
as patients in neighbouring beds might overhear.
Returning to Aroskar et al. (2004), changes in the focus of the nursing function were
thought to impact on patient care with the blurring of professional boundaries; nurses
taking on responsibility for an increasing number of technical interventions led to a
lack of time being available for the development of meaningful nurse-patient
relationships. In conjunction with these changes in nurses’ roles, unregistered and
unregulated staff were taking on aspects of care that were perceived by some
51
nurses to have a negative impact on the quality of care and, in some cases, to have
put the patient at risk.
Aroskar et al. (2004) also identified how nurses perceived that policy changes had
resulted in there being insufficient nursing staff to implement primary or team
nursing, leading to reduced job satisfaction and an increase in staff turnover. The
consequences of this were that nurses faced dilemmas about equity in care
provision and compromised standards, which caused them moral distress. Their
participants indicated that there was a lack of input from nurses in the development
of local policy but that it was often nurses who faced the impact of such policies on
patients and their families. This lack of involvement in policy development resulted
in nurses feeling that their contribution was not valued. Finally, they identified that
ethical dilemmas also occurred when organisational policies conflicted with care
policies within the same hospital.
2.3c Moral distress
It is clear from analysis of professional codes governing individual nurses’ behaviour
and of policy directives giving structure to care delivery that nurses frequently feel
unable to give optimal care. This feeling is described in the literature as ‘moral
distress’. Nurses’ moral distress occurs when it is perceived that an acceptable
solution to an ethical dilemma is not achieved. Areas which cause moral distress
include organisational constraints which result in limiting the nurse’s ability to
undertake what is perceived to be the correct course of action (Corley, 2002). Moral
distress occurs when a person’s moral integrity is challenged; when there is
inconsistency with what is believed to be the right thing to do and the action taken in
52
a given situation (Hardingham, 2004). When moral distress occurs nurses may
experience loneliness and a feeling of isolation due to a lack of mechanisms to
facilitate dialogue (Sørlie et al., 2003).
Situations which cause moral distress amongst nurses, as identified by Kalvemark et
al. (2004), include those where organisational constraints and, in some cases, legal
issues, result in conflict or compromise standards of care, concluding that there is a
need for structures, education and resources to help reduce moral distress amongst
all heath care professionals. Corley’s (2002) review of the literature highlights a
broader range of causes of moral distress amongst nurses. This review suggests
that moral distress may occur when treatment is viewed as causing pain or harm;
when suffering is prolonged; and when contextual problems associated with
bureaucracy and inadequate management occur.
A number of issues that directly impact on nurses’ perceived stress levels were
identified by Ulrich et al. (2010). Low staffing levels were found to cause the most
stress amongst nurses. The dilemmas which occurred most frequently were
protecting patients’ rights, autonomy, informed consent, advanced care planning,
surrogate decision making, end of life decision making, breaches of confidentiality,
and patients’ right to privacy, all of which resulted in moral distress when a
satisfactory outcome could not be found. In addition, limited staff to implement care
and facilitate decision making has the potential to impact on all aspects of care.
Nurses’ involvement in decision making is further highlighted in Long-Sutehall et al’s
(2011) qualitative study involving 13 semi structured interviews with registered
53
nurses working in critical care units in four different hospitals, which indicated that
nurses have limited involvement in decisions associated with the withdrawal of
treatment. However, nurses are expected to implement the plan of care and when
this is contrary to what they believe is morally right, moral distress occurs. The
researchers concluded that doctors, who make these treatment decisions, have a
different underpinning professional philosophy which focuses on extending life,
whereas it is likely that nurses may consider allowing life to end to be the appropriate
course of action.
Explorations of nurses’ and doctors’ perceptions of ethical problems involved in end
of life care indicated that nurses’ concerns resulted from their lack of involvement in
decision making, even though it is the nurses who are required to execute the care
plan (Oberle and Hughes, 2001; Long-Sutehall et al., 2011). The lack of involvement
by nurses in this type of care is supported in an examination of the ethical issues and
nurses’ moral distress associated with euthanasia (Dierckx de Casterle, et al., 2010).
Looking specifically at euthanasia, Dierckx de Casterle et al. (2010) identified that
nurses have a crucial role in decision making, as they spend time with the patients
building a trusting relationship. The importance of the involvement of the whole
palliative care team in deciding to provide the treatment requested was highlighted
within the interviews undertaken with participants. Although the physician makes the
final decision based on the group discussion, shared decision making was viewed as
essential because it is more often the nurses who have a key role in implementing
the care plan and supporting the patient and their families.
54
Kain’s (2007) examination of the literature supports the idea that nurses experience
moral distress when conflict occurs between what the nurse may perceive to be the
best course of action and what is possible within organisational policies, resourcing
issues and different opinions on prescribed care. Responses to this distress include
sorrow, guilt, frustration and anger which, if left unaddressed, may threaten nurses’
self worth, the consequences of which may impact on both personal and
professional relationships. Moral distress can also occur due to conflict with the
health care team, particularly where there are clear differences between the priorities
of nurses and doctors in relation to patient care and differences in each profession’s
mandate to care (Oberle and Hughes, 2001). This is explored further below.
Wolf and Zuzelo’s (2007) analysis of nurses’ ‘never again stories’ echoes concerns
regarding nurses’ lack of involvement in decision making and the distress they
experience in association with this. This empirical research, using a qualitative
approach, highlighted the participants’ understanding of how failing to contribute in
addressing complex ethical dilemmas, even though the constraints placed upon
them were as a result of organisation policy or the hierarchal nature of health care,
resulted in their distress. Through critical reflection nurse participants were able to
identify if they could have acted differently and what they would do if faced with a
similar situation. However, the nurses still felt that they had failed in their obligations
to those in their care.
If not addressed the consequences of this moral distress for individual nurses and
the nursing profession are that nurses suffer burn out. This may involve becoming
desensitised to the dilemmas, as a way of avoiding the distress previously
55
experienced, it may also mean they may choose to leave the profession altogether
(Coley, 2002; Hardingham, 2004; Ulrich et al., 2010: Palvish et al., 2011). In both
cases burn out has the potential to impact negatively on patient experience.
Corley (2002) does, however, acknowledge some benefits of moral distress,
suggesting that moral distress instigates a process of learning and reflection
facilitating personal and professional growth through experience, resulting in the
potential for future patients to receive more compassionate care. Moral distress
occurs when a person’s integrity is challenged; moral integrity is the connection
between a person’s beliefs, values and actions as a professional and as an
individual (Corely, 2002). Hardingham (2004) suggests that critical reflection on
values, beliefs and social influences in a given situation may help the achievement of
a sound understanding of experiences in practice; through this process and
socialisation into the profession the nurse may achieve moral integrity.
Nurses are expected to maintain standards of care beyond their personal motivation;
a duty is placed upon them by the NMC in its Code (NMC, 2008) and by the
Department of Health (DH, 2008; Francis, 2013). The importance of maintaining
standards of care has recently been emphasised in the Report of the Mid
Staffordshire NHS Foundation Trust Public Inquiry, where nurse leaders are charged
with providing strong leadership to ensure the failings identified in this report do not
reoccur (Francis, 2013). This report highlights that nurses did raise their concerns
about standards of care but felt powerless to bring about change, a situation Corley
(2002) identifies as leading to moral distress.
56
It would therefore appear that moral distress is a well-recognised but not fully
explored phenomenon in health care which may be associated with organisational
constraints as well as with dilemmas in decision making. There are clear links
between the tensions leading to moral distress and the balance between moral
reasoning, ethical decision-making and action outlined in the theoretical framework
in Chapter 1. This will be explored further in the discussion in Chapter 10 of this
thesis. A final area identified in the literature and related to moral distress is the
tension between managing conflict and collaboration with ethical decision making.
2.3d Conflict and collaboration within ethical decision making
A frequent source of conflict evident within the literature is between the doctor and
the nurse directly involved in patient care. This appears to occur in different aspects
of ethical practice, for example within the process of decision making and in
communicating with patients and their relatives. Organisational constraints and the
hierarchical structures within hospitals may be contributory factors in such conflicts
(Heikkinen et al., 2006; Ulrich et al., 2010).
Nurses describe ‘working in between’, in Varcoe et al.’s (2004) study, which used
focus groups to explore the experiences of eighty seven nurses. Working ‘in
between’ is how nurses described finding a balance between their own values, those
of the patients, of other health care professionals and of the organisation, to do what
is felt to be ‘good’, acting as moral agents. This process was described by
participants as problematic and resulting in professional and personal struggle.
Nurses consequentially experience conflict with a number of groups; physicians, the
57
organisation and its representatives (managers) and other health care professionals
(Redman and Fry, 2000).
Conflict may also occur in nurses’ perceptions of what is expected from their role.
Hyde et al. (2005), in an analysis of nursing documentation in a multisite study
undertaken in Ireland over a 5 year period, found that whilst there has been an
emphasis in nursing theory on the biography of the individual and the personal
experience of illness, there was little evidence in the documentation that nurses
practised this; physical aspects of care appeared to take precedence over patient
autonomy. It therefore appeared from the nursing documentation that ‘biology’ took
precedence over ‘biography’. This would be in line with biomedical approaches to
patient care and values that have been informed by medicine and may be in conflict
with perceived expectations of caring about, as well as for, the patient.
Peter et al. (2004), in a literature review of empirical studies undertaken between
1993 and 2003, concluded that much of the conflict identified resulted from nurses’
perceived moral duty to promote patients’ wellbeing. They and others (Storch et al.,
2004) suggest that a unique relationship develops between the patient and the nurse
but that this can lead to conflict with other health professionals as the nurse assumes
the role of advocate, a role that is indicated within The Code (NMC, 2008).
However, some groups of nurses are less able to build on this relationship to assert
their views or advocate for their patients. These include junior nurses (Peter et al.,
2004) and nurses working in long-term care, (Varcoe et al., 2004). Other
participants in Varcoe et al.’s (2004) study described how they chose which conflicts
58
to address and when not to challenge others; this may be viewed as failing to meet
the potential the nurse has in promoting patient well-being.
Oberle and Hughes (2001) recognise that when conflict occurs, resulting from the
nurse’s inability to influence ethical decision making by doctors, nurses experienced
moral distress. They suggest that the differences in nursing and medical values and,
consequently, priorities, can explain some of this conflict. Doctors have, in many
cases, the responsibility of deciding on treatment regimes and the nurse’s
responsibility is to deliver care which incorporates these regimens.
Nurses interviewed by Oberle and Hughes (2001) discussed competing values and
how these were managed in situations where the patient was unable to speak for
themselves. Discussions during the decision making process would include ‘what the
patient would want’. Conflict between doctors and nurses was described in cases
where the doctor or doctors involved thought it best not to fully involve the family who
might know the patient’s view and values better than the team, with the doctors
arguing that the family might not understand the full implications of their decision on
the patient. Nurses opposed this paternalistic approach and felt that doctors often
acted according to their own values and beliefs rather than respecting those of the
patient.
Challenging doctors’ orders or other aspects of poor care is something clearly
required in The Code (NMC, 2008). However, Oberle and Hughes (2001) suggest
that there is some evidence to indicate that the hierarchical structures within the
organisations and the roles doctors and nurses take result in each being faced with
59
different ethical problems in the same circumstances. They therefore ask different
questions according to their role rather than there being direct conflict between their
values. Thus, it may be that it is the organisational structure and the culture of
doctors’ authority that place the nurse in a disempowered position when addressing
morally challenging situations in practice, resulting in nurses’ lack of autonomy in
such cases (Liaschenko and Peter, 2004).
Nurses have been found to ‘bend’ the rules in order to achieve a satisfactory
outcome, especially in cases where the organisation is less responsive to the need
for flexibility or where there is no clear guidance or policy in place to facilitate
decision making in ethically challenging situations (Redman and Fry, 2000).
Redman and Fry’s literature review highlighted how different types of conflicts are
experienced by nurses according to their specific role. All nurses experienced some
kind of conflict and 33% experienced moral distress, which they attributed to
institutional constraints, making it extremely difficult, and in some cases impossible,
to take the ‘right’ action. This is discussed further in Chapter 7.
Palvish et al. (2011), following a 70 participant descriptive qualitative critical incident
study, concluded that the key to addressing ethical dilemmas associated with patient
care was early identification of potential problems. It is recognised that this is more
likely to occur where patients are particularly vulnerable or have multiple problems.
Their results suggest that effective communication mechanisms are essential, as
these promote collaboration and avoid underrating the viewpoints of others with
whom the moral conflict may arise or has arisen.
60
Salloch and Breitsameter (2010) examined the moral conflicts in hospice care, by
undertaking a qualitative study involving nurse participants in focus group
discussions. They identified how nurses recognised external ethical standards and
referred to the internal organisational philosophy that each patient should be valued
and should not be judged by their decisions or social background. They concluded
that this respect for patients’ dignity is paramount in ensuring that the ‘right’ action is
taken.
The importance of involving others within decision making is also highlighted in
Vandrevala et al’s (2006) study which indicates that involving others brings a range
of perspectives, recognising that it is important to involve the doctor whose
knowledge and understanding of the patient’s physical condition and prognosis are
essential. The risks of leaving the decision to the doctor alone were associated with
doctors’ professional commitment to maintaining life. Furthermore, the close
relationship that family members have with each other and with the patient may put
them in a good position as they may know the patient’s wishes (if the patient does
not have capacity). However, this close relationship may also make decision making
difficult for them.
Having the opportunity to contribute to the decision making process is particularly
important for nurses who are charged with implementing the plan of care (Dierckx de
Casterle et al., 2010). Nurse participants involved in Dierckx de Casterle et al.’s
study explained the importance of the nurse’s voice being heard, as it is the nurse
who has a unique relationship with the patient and provides ongoing care, spending
a substantial amount of time engaging with the patient, which enables them to
61
develop an understanding of the patient’s views and expectations. Lamb and
Savdalis (2011) recognise that collaborative decision making is highly valued in
various aspects of patient care and decision making and that care provided for
anyone with complex needs has become a multi-disciplinary activity in order to
ensure the best available care for patients.
Shared decision making within the health care team, especially between the nurse
and doctor, is a key contributor to patient care and is essential if good quality care is
to be achieved with ethical decision making being undertaken and negotiated within
the team (Botes 2000a; 2000b). Botes opposes a classical rational approach to
ethical decision making, suggesting that the use of universal principles embedded in
this approach is inadequate and calling for health professionals to interpret the
appropriateness of the decisions taken in each individual situation. This
interpretation requires moral agency to be undertaken by the health care
professionals involved; recognising and respecting the views of all those involved in
the negotiation and application of general principles and guidelines. Participants in
these discussions must also be aware of their own values and the impact these may
have on their contribution (Botes, 2000a; 2000b).
2.4 Conclusion
The themes identified from the literature review are linked, each impacting on and
informing the other. Resolution of ethical dilemmas occurs within the context of
professional codes and policy directives that govern individual and collective
behaviour. Moral distress and the tensions between conflict and collaboration
62
emerge as consequences of the difficulty nurses [and other health professionals]
face in attempting to achieve ethical decision making in practice.
Situations where moral distress is experienced by nurses include where care is
perceived to be restricted by national and organisational policy or limited resources
and when there is conflict within the health care team (Ulrich et al., 2010). Conflict
occurs between nurses and other health care professionals particularly when nurses
are not involved in decision making but are required to deliver a plan of care which
they feel is unethical. This may be because the care delivered is contrary to the
patient’s wishes and value system or where treatment appears to be causing pain or
prolonging suffering (Corley, 2002). The impact of moral distress for some nurses
can result in burn out and moral insensitivity or in the nurse leaving the profession
(Corley, 2002; Hardingham, 2004; Ulrich et al., 2010; Palvish et al., 2011). Moral
distress has the potential to impact negatively on the standards of care received by
patients (Ulrich et al., 2010). Furthermore, the effects may also impact negatively on
professional relationships and nurses’ personal relationships (Kain, 2007).
Ethical practice amongst nurses is viewed as relational in the shifting context of
health care and nursing practice (Varcoe et al., 2004). Conflict of values may occur
with patients, peers and managers, causing moral distress and challenge to nurses’
ethical decision making (Corley et al., 2002). Effective communication is essential if
solutions are to be found and appropriate decisions made in relation to ethical
dilemmas that arise within a patient’s plan of care (Palvish et al., 2011).
63
The Code (NMC, 2008) indicates that nurses must ‘Make the care of people your
first concern, treating them as individuals and respecting their dignity’ (page 3) and
‘Provide a high standard of practice and care at all times’ (page 6). This indicates
that nurses have a professional duty to engage in ethical decision making. Thus,
codes of ethics for nurses attempt to provide the basis of professional and ethical
practice. Critical discussions of prior research presented in this chapter support the
argument that although these codes may appear to be the cornerstone of ethical
practice they appear to provide little guidance for individual ethical dilemmas.
However, Banks (2003) indicates that this approach facilitates the nurse as moral
agent to make decisions based on principles rather than fixed directives.
Standards of care and ethics are viewed by Palvish et al. (2011) as inseparable,
therefore, when minimum standards of care are not met, ‘ethical concerns’ arise.
These authors go on to suggest that ‘ethical concerns’ are thought to be increased
when a patient is particularly vulnerable and has multiple diagnoses and, in this
context, nurses are both willing and able to contribute to ethical decision-making.
Since the introduction of Project 2000, nurses have been educated in ethics and
critical thinking skills to support the application of ethical principles, therefore acting
as moral agents rather than applying strict rules (Varcoe et al., 2004).
Nurses’ ability to influence policy and treatment regimens for patients when ethical
dilemmas occur in practice may be affected by professional and organisational
hierarchical structures. It may therefore be that nurses are inclined to make
decisions based on convention and policy, (Dierckx de Casterle, et al., 2010).
64
Corley (2002), however, indicates that some nurses ‘bend’ the rules to promote
patient wellbeing.
Nurses are frequently faced with ethical dilemmas in practice, however they may
experience moral distress which can remain unresolved when they feel excluded
from the decision making process and are uncomfortable with the outcome. The
conflict that occurs is predominately between doctor and nurse, however
organisational policy and the lack of resources also have an impact on standards of
care and on nursing decision-making.
2.5 The aim of the study
In Chapter 1 this thesis set out to identify the values, beliefs and contextual
influences that inform decision making and the contribution made by registered
nurses in achieving the resolution of ethical dilemmas in nursing practice.
In Chapter 1 a theoretical framework was introduced that set out a staged approach
to ethical decision making the nurse through from moral reasoning to action. This
chapter has developed the context in which the theoretical framework may be
applied, identifying, through the literature, professional codes and policy as well as
moral distress, conflict and collaboration. There appears to be a lack of clarity
regarding ethical decision making within the context of secondary care nursing
practice and the need for greater understanding of the concept of moral distress
within nursing. The aim and objectives of the study are therefore confirmed as:
65
Aim of the study:
To identify the values, beliefs and contextual influences that inform decision making
and the contribution made by registered nurses in achieving the resolution of ethical
dilemmas in nursing practice.
Objectives
1. Identify underpinning values and beliefs which impact on nurses’ ethical
decision making and moral action.
2. Critically discuss new themes which are generated from the data in the light of
current literature.
3. Identify the contextual influences which impact on nurses’ ethical decision
making and moral action.
4. Discuss the implications of the study findings for future nursing practice.
66
Chapter 3 – Study Design
3.0 Study design/ Methodological justification
Qualitative exploratory research was considered the most appropriate approach for
this study. A descriptive approach might result in describing the phenomena of
interest and this provides the initial justification for the approach to methods within
this study. However, in order to understand the full nature of the phenomena within
the identified context, a broad exploratory approach was taken, encompassing tenets
of an interpretative approach to data collection and analysis. (Denzin and Lincoln,
2003; Parahoo, 2006; Polit and Beck, 2008). Those tenets did not encompass
issues of saturation and, therefore, sampling was not based on this and was more
consistent with, for example, a ‘descriptive phenomenological’ methodology
(Colaizzi, 1973; Mason, 2010). The processes of data analysis in this study were
designed to facilitate comprehensive interpretation of the data. It was considered
that selecting a single approach might result in excluding certain aspects from the
analysis and interpretations (Morse and Chung, 2003). By using a flexible approach
it was envisaged that the process of analysis used would facilitate interpretations
that brought understanding, not only of what nurses do when addressing ethical
dilemmas but why they act in this way, what it is that informs their reasoning and
decision making (Denzin and Lincoln, 2008).
3.1 Data collection
Following a pilot study to determine the most appropriate data collection method, it
was decided that the main study would utilise semi-structured interviews of a
purposively selected sample, based on the population sampling strategy outlined
later in this chapter (Gerrish and Lacey, 2006; Polit and Beck, 2008; Burns and
67
Grove, 2009). Field notes made during and following interviews would be used as
additional data (Polit and Beck, 2008).
3.2 Pilot study
The pilot study was undertaken from January 2009 to September 2009. The findings
of this resulted in some changes to the original project design and the guiding
questions developed for data collection.
The pilot study was used to evaluate the selected data collection method and to
check that the selected approach would result in the collection of appropriate data to
inform the study (Silverman, 2010). This was a small pilot study as the nature of this
project was time and resource limited. Once sufficient data had been collected to
indicate any changes required in the approach and provide some indication as to the
availability of data, the pilot study was concluded (Parahoo, 2006; Polit and Beck,
2008; Bowling, 2009; Burns and Grove, 2009). Three participants were involved in
the pilot study. The pilot study interviews were completed using guiding questions,
which were consequently amended. Flexibility regarding how to use and phrase
these guiding questions varied as the focus was driven by the participant (Pilot and
Beck, 2008; Burns and Grove, 2009; Hennick et al., 2011). This was important as
one aim of the study was to understand not only what nurses do in relation to ethical
dilemmas but what it is that informs these actions or contributions.
3.2a Pilot study: Ethical approval
Ethical approval was granted by the School of Human and Health Sciences
Research Ethics Panel and the Head of Department where the pilot study was
68
conducted. This provided access to employees within a specific academic
department and facilitated the evaluation of the data collection methods. All
participants were provided with the information required to gain informed consent.
All data was anonymised and stored securely. It is important that where live
participants are involved, informed consent is sought and confidential data is treated
in line with the Data Protection Act 1998.
3.2b Pilot study: Participant recruitment
Pilot study participants were recruited from registered nurses working as lecturers
within nurse education. It was important that pilot participants reflected the target
population for the main study (Hennick et.al., 2011) therefore a purposive targeted
approach was used. Three participants with recent experience as nurses within
secondary care provision were specifically recruited.
Sample frame for the pilot study:
Registered nurse on the NMC register.
Have worked within the secondary care provision.
Recruited voluntarily
Able to provide informed consent.
Available to participate within the specified time frame.
3.2c Pilot study: Data collection
Audio recording of semi structured interviews was used; this allowed the participant
the freedom to tell their personal story within the context of their practice. It also
facilitated the capturing of the full extent of their experience (Holloway and
69
Freshwater, 2007; Silverman, 2010). The length and direction of the interview
remained participant driven; the guiding questions and prompts were only used when
participants required encouragement to further explore their experiences. Each
interview lasted between 30 and 45 minutes (Polit and Beck, 2008).
Guiding questions used for the pilot:
1. Can you tell me about an ethical dilemma you have faced in your recent
clinical practice?
2. What exactly happened?
3. What did you do?
4. How did this make you feel?
Whilst undertaking the pilot study it became clear that this provided an opportunity
for the researcher to develop interview skills, becoming familiar and more
comfortable with the situation and process (Silverman, 2010). Having undertaken
the pilot study researcher confidence was increased and strategies were developed
to ensure participants felt comfortable (Silverman, 2010).
Data collection was conducted after obtaining informed consent. The interviews
were conducted in a private office away from any interruptions. Participants were
given the participant information sheet (see Appendix 4) and provided with time and
opportunity to ask questions and discuss any concerns they might have prior to
signing the consent form (see Appendix 5). Participants were advised that they
might withdraw from the study at any time and if they wished recording to stop at any
70
stage in the interview they should just indicate this. All participants had access to
university counselling services should this have been required.
Field notes and personal reflections were undertaken by the researcher to inform the
development of the research skills associated with data collection and analysis
(Holloway, 2005).
3.2d Pilot study: Data analysis
Initial descriptive data analysis of the pilot study interviews identified the broad
themes detailed below. Interactional dimensions within the accounts were also
identified. These were explored further within the main study.
In order to facilitate data analysis a verbatim transcript was made. The transcript
was presented to the participant to ensure this was a true reflection of their personal
experience. Once agreed, the thematic analysis and interactional analysis were
undertaken, supported by the use of Nvivo 8 software package.
Analysis was undertaken by the primary researcher, which involved verbatim
transcription in the first instance. Though this was time consuming the decision to
undertake this was made as it provided an opportunity to become familiar with the
data and begin analysis.
Thematic analysis was used initially as this breaks the data into separate
components, facilitating comparison between transcripts and the identification of any
emerging common themes (Polit and Beck, 2008). Dismantling of the data is the first
71
stage of analysis followed by reassembling of the themes resulting in the
interpretation of the data (Hennick et al., 2011). In this case the researcher had
experience of ethical dilemma resolution in this context which might have influenced
the interpretation of data. Some of the findings within the pilot study did not match
fully with this experience although they did reflect some previously observed
incidences.
3.2e Pilot study: Findings
The main themes that emerged from the pilot data were:
1. To do ‘what was best for the patient’ appears to be at the forefront of the
decision making process.
2. All the accounts identified autonomous decision-making.
3. There was an acknowledgment of accountability by each of the
participants.
Interactional aspects included:
1. Engaging with others to find a resolution.
2. All participants acknowledged that these decisions had an impact on
others, which also needed to be considered.
3. Whilst the participants acknowledged the importance of collaborative
working, there appeared to be a belief that ‘management’, or ‘the powers
that be’, placed constraints on their practice through policy,.
Recommendations:
1. Guiding questions required reviewing and further development
72
2. To continue with the main study as described above.
3.3 The Study
The study was undertaken in a single NHS Trust across two sites. This provided
access to nurses working in a variety of roles, with a range of experience and levels
of responsibility, within secondary care provision.
3.3a Population
In this case the total population was all registered nurses, from all fields of nursing,
working within the United Kingdom within the context of secondary care provision.
The Nursing and Midwifery Council in 2010 had 676,547 nurses on the register
(NMC, 2010b). Nurses work in primary care, secondary care and in associated
fields such as education and management. The target population was those
registered nurses working in a single acute NHS Trust, which is referred to as The
Trust throughout this paper, from which the sample population was drawn (Gerrish
and Lacey, 2006).
3.3b Sampling strategy
Inclusion criteria
Registered nurse on the NMC register.
Working within secondary care provision.
Recruited voluntarily.
Able to provide informed consent.
Available to participate within the specified time frame.
73
Purposive sampling was used to recruit the participants. It was important to ensure
that there was the potential to recruit participants with a range of diverse experiences
to facilitate conceptual generalisation and to strengthen the validity of the study
(Gerrish and Lacey, 2006). In total, including the pilot and main study 11 participants
were recruited.
Given the broad nature of the approach in this study, and that there is a longitudinal,
equivocal debate in the literature of the notion of an appropriate sample range, depth
and size in qualitative research, it is considered pertinent to briefly critically discuss
this aspect of the design (Sandelowski 1995; Marshall 1996; Curtis et al., 2000;
Mason, 2010). Much has been written on the subject of sample size in qualitative
research studies, with little consensus as to whether it is an appropriate discussion
per se, what constitutes a ‘size, or indeed what that ‘size’ might mean (Curtis et al.,
2000). Sandelowski (1995) has discussed that sample size may well indeed be
important in qualitative research, however he also states that it rests within the area
of researcher judgement and experience, the particulars of an individually designed
study and the depth of the data to be collected. Authors have also attempted to
provide guides as to appropriate sample sizes against particular approaches with, for
example, phenomenology indicating a size of anywhere between 5 and 25 (Creswell,
1998; Mason, 2010). What is argued here, within the justified, broad exploratory
approach to this study, is that the important drivers for the purposive sampling
procedure detailed in this chapter were the ranges of experience, perception and
depth of individual narratives rather than notions of saturation or a ‘pseudo-scientific’
application of ‘representativeness’ .
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3.3c Recruitment
The planned process of recruitment was followed from within The Trust. In the first
instance clinical area managers were approached in writing, including a copy of the
participant information. The aim was to gain permission to visit the clinical area to
talk to registered nurses who might consider participating in the study. After several
meetings to introduce the study to prospective participants a number of volunteers
were identified.
Participants were recruited from a variety of areas within The Trust, which included
general medicine, vascular surgery, general surgery, intensive care, care of the older
person and children's services. The participants had a range of professional
backgrounds and experience. Some trained and worked in a single Trust, others had
worked in a variety of Trusts, potentially giving them broader and different
perspectives. Experience ranged from 2 years to 40 years. The sample consisted of
Staff Nurses, Junior Charge Nurses and Senior Charge Nurses, all of whom worked
clinically. All but one of the participants was female.
Whilst the sample frame above provided some level of purposive sampling, this did
not include precise selection in relation to educational background or experience.
Participants recruited were initially assigned a code then for the purposes of
presenting the findings, a pseudonym.
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Table 1: Participant Profile
Participant
code
Practice area
Experience Pseudonym
P01 Medicine for the older
person / acute
assessment
Charge Nurse 30 years
experience
Sam
P02 Medicine for the older
person / acute
assessment
Deputy Charge Nurse
2.5 years experience
Chris
P03 Children’s Services Charge Nurse 40 years
experience
Ashley
P04 Surgery
Staff Nurse 30 years
experience
Charlie
P05 Surgery Charge Nurse 20 years
experience
Brooke
P06 Surgery Staff Nurse 2 years
experience
Jordan
P07 Surgery Staff Nurse 9 years
experience
Jo
P08 Intensive care unit Charge Nurse 10 years
experience
Nicky
P09 Rehabilitation Staff Nurse 25 years
experience
Lee
P10 Acute medicine Staff Nurse 18 years
experience
Drew
P11 Care of the older
person
Charge Nurse 26 years
experience
Ross
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3.3d Ethical considerations
As this research involved interviewing live participants and the discussion of
sensitive situations relating to National Health Service patients and other National
Health Service staff, it was important that appropriate ethical approval was obtained
(Polit and Beck, 2008). Ethical approval from the National Research Ethics
Committee and the School of Human and Health Sciences Research Ethics Panel
was granted. A letter of access was provided by The Trust Research and
Development Unit.
Participants were fully informed of the purpose of the study and provided with
information about this prior to consenting to participate (see Appendix 6). Written
informed consent was obtained from the participants prior to the interview
commencing (see Appendix 7) (King and Horrocks, 2010).
One volunteer chose to withdraw following the commencement of the interview as
she felt that it was difficult to discuss some of the decisions in which she was
involved; this individual had approximately four years practice and worked in acute
settings prior to the situation in which she was employed at the time of the interview..
All data collected was treated confidentially; each participant was allocated a
reference number and all personal data kept separate from the collected audio
recording and transcription. All recording and transcription files were password
protected. All printed transcriptions and consent forms were stored in a locked
cabinet on the University of Huddersfield premises, in a location that had restricted
access.
77
The Trust’s staff counselling service was accessible for any participant who might
have experienced psychological or emotional distress following the interview. An
attempt to minimise this risk was made by asking participants to identify the
experiences they wished to share and discouraging them from sharing anything they
were uncomfortable with. None of the participants reported having suffered any
psychological distress from participating in the study.
3.3e Data collection
Data were collected from registered nurses currently practising in the context of
secondary care, recruited from The Trust. There were a variety of data collection
approaches available within the qualitative paradigm. The aim of these approaches
is to access the rich source of data required to explore qualitative issues; these
include individual perspectives and experiences (Grbich, 1999; Denzin and Lincoln,
2003; Parahoo, 2006; Polit and Beck, 2008; Bowling, 2009; Burns and Grove, 2009).
Semi structured interviews were used to capture the nurses’ experience, told in their
own words from a personal perspective. This was particularly useful here as this
type of data provided insight into the participants’ perspectives about the ’why and
how’ within a situation (Gerrish and Lacey, 2006; Bowling, 2009). Interviews of this
nature, however, can be time consuming to undertake and to analyse (Polit and
Beck, 2008; Burns and Grove, 2009). A time consuming aspect of this approach
was not only the interview; on occasions more than one visit to the practice setting
was required as the demands of the clinical environment can quickly change and
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where an acute situation had arisen a new appointment was made to ensure that the
research process did not impact negatively on service provision and patient care.
The interview process provided the opportunity to build rapport with the participant
and so encourage the participant to disclose more about their experiences (King and
Horrocks, 2011). Participants were put at their ease. To help achieve this the
interviews undertaken were performed face to face and followed an informal path,
using guiding questions to provide the interviewer with tools with which to support an
engagement of conversation between participant and interviewer (Polit and Beck,
2008; Burns and Grove, 2009). Efforts were made to keep the interview process
participant led, as it was important that the data collected reflected the participants’
perspectives. This provided participants with the freedom to explore and focus on
issues which were of importance to them within the experience they had chosen to
discuss. The aim was to capture the participants’ personal experiences, their
interpretation of those experiences and to identify the meaning the participants had
attached to the personal experiences discussed (Holloway, 2005; Gerrish and Lacey,
2006; Parahoo, 2006).
The very first stages of data analysis began during the interview, with the very first
interview indicating some of the themes to be explored (Hennick et al., 2011).
The physical environment is also important when undertaking interviews. The
participant and interviewer should feel physically and psychologically comfortable. If
the participant feels uncomfortable this may result in limited responses to the
interview questions (King and Horrocks, 2011). Interruptions and disturbances can
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also result in limited data collection as the participant may lose their train of thought,
as might the interviewer. It is important to ensure that sufficient time is available to
put the participant at ease, obtain informed consent and allow for the participant’s
questions prior to commencing the interview and for possible discussion following
the interview (King and Horrocks, 2011). Therefore, one and a half hours were
allowed for the whole process.
In this instance participants were interviewed in their place of work as this was most
convenient for them. A quiet place was identified and a ‘Please do not disturb’ notice
was situated on the door to the room. Some instances of disturbance did occur but
only when the participant was needed to attend to patient matters urgently. When
working with registered nurses who have a responsibility for patient care this may be
an issue, however it was acknowledged at the beginning of each interview as
unavoidable.
Guiding questions used for the main study
Once the pilot study interviews were completed and the pilot data analysed, the
guiding questions were amended to include further probing questions. These
questions were used flexibly according to how the interview was progressing and to
maintain a participant centered approach, ensuring that the content was driven by
the participant (Gerrish and Lacey, 2006).
Following the use of an opening question about the participant’s background and
experience as a registered nurse, which was designed to help them become more
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relaxed with the interview process, the following introductory open question was
used.
‘Can you tell me about an ethical dilemma you have faced in your recent
clinical practice, within the last three years?’
Once the participant had begun to share their experience the following questions
were used as required:
1. What exactly happened?
2. How did this make you feel?
Why do you think you felt this way?
3. What did you do?
4. What made you act the way you did?
5. What was the final outcome?
Were you happy with this?
3.3f Data analysis
This research falls within the interpretive paradigm as described by Hennick et al.
(2011) as the ethical dilemmas discussed occurred within the context of nursing
practice which has a professional, cultural and personal dimension. The process of
analysis was undertaken as planned, following verbatim transcription of the recorded
narrative. The transcribed documents were repeatedly read whilst listening to the
audio recordings. This was undertaken firstly to correct any transcription errors
which may have occurred and secondly to ensure familiarity with the data collected.
The aim of analysis in qualitative research is to repeatedly scrutinise the data to
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identify meaning and bring understanding so as to recognise emerging themes and
theory (Polit and Beck, 2008). Listening to the transcripts ensured that emphasis
and indications of any emotion or uncertainty were appreciated and acknowledged in
the analysis of the data collected (Hennick et al., 2011). The transcribed documents
were then imported into Nvivo 8 for analysis.
Computerised software selection
The software was used for coding data according to emergent themes and retrieval
of coded sections. Theory construction was undertaken through critical analysis
undertaken by the researcher. There are benefits and disadvantages which needed
to be considered when deciding to use computerised software to support the
analysis of qualitative data (Polit and Beck, 2008; Riessman, 2008). Computerised
software can be used to support a variety of data formats - written, audio and video
data - and may also be used for coding of data during analysis, as it has been within
this study. It may also be used to support theory construction (Lewins and Silver,
2007). Conceptualisation of the theoretical framework was not undertaken using
computerised software.
Analysis and consequent interpretation of the collected data were undertaken using
two recognised approaches:
Thematic analysis
The objective of thematic analysis is to identify themes from within the transcript
considering what is being said (rather than to whom it is being said) and the purpose
of the engagement, (Riessman, 2008).
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Coding themes as they emerge from the data was the approach selected and used
in the initial stages of data analysis, providing a description of the situations
discussed and the actions taken by the nurses taking part (Silverman, 2010).
Analysis involved reading the transcript several times to become familiar with the
data and to identify the emergent themes (Polit and Beck, 2008). An inductive
approach was undertaken as the data analysis was ongoing whilst data was being
collected (Hennick et al., 2011). Themes were named by the researcher to indicate
their meaning.
As more data was analysed it became apparent that subthemes could be identified.
These are discussed within the results in Chapters 4 to 8. Data collection was
concluded after the 11 interviews from the main and pilot studies. Data collected
from pilot study participants reflect that collected within the main study. At this point
the data collected from participants contained a number of common themes and it
was evident that there were sufficient data to address the study aim with some level
of confidence. Conducting further interviews may have resulted in redundant data
and would have been an inappropriate use of participants’ time (Burns and Grove,
2009).
Interactional analysis
Interactional analysis was also performed to place the contribution nurses make to
resolving ethical dilemmas in the context of nursing practice and to examine how the
relationships and culture within that practice area have impacted on the contribution
made (Holloway and Freshwater, 2007).
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Content analysis
One ethical dilemma from Charlie’s account was selected to be viewed as a whole
(see chapter 9) and the process of content analysis was undertaken; this also
facilitated the examination of decision making, relationship development and the
articulation of the contribution made by Charlie (Holloway and Freshwater, 2007).
The accounts provided by the participants help to bring an understanding of the
context and to recognise the individuals within each account. These accounts are not
simply descriptions; they are filled with emotion, values and interpretation on the part
of the participants (Holloway and Freshwater, 2007).
The analysis provided the opportunity to develop an understanding of the whole
process and the complexity of the decisions undertaken when addressing ethical
dilemmas in nursing practice. In doing so it offers a critical revision of the theoretical
framework which is outlined in Chapters 9 and 10. This type of analysis allows for
understanding of the participant’s view of the incident as a whole (Holloway and
Freshwater, 2007) rather than as separate components to be examined individually,
as has been undertaken in the thematic analysis.
These accounts have the potential to help recognise the meaning of the routine
activities undertaken, for the participant as much as for the researcher (Holloway and
Freshwater, 2007). The sharing of an experience can act as a form of reflection,
bringing new understandings to previous experiences (Holloway and Freshwater,
2007). This was particularly evident for pilot study participant Ross who stated:
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‘Probably it was in hindsight, reflecting on it now which I have not done for a
while probably happened correctly.’ Ross
3.3g Validity and reliability
There has been much debate regarding validity and reliability in qualitative work.
Some authors prefer the terms credibility and dependability (Denzin and Lincoln,
2003), whilst others argue that the terminology should remain the same, only the
processes by which this is judged should differ (Long and Johnson, 2000). The main
point is that the research should evidence precautions made to ensure that the
research has been rigorously performed.
Key aspects undertaken to increase rigour were:
Reflexivity
A reflective diary was kept throughout, which included key decisions; this was used
to facilitate reflexivity within this research. Reflexivity within narrative research
should be continuous, the researcher reflecting during each stage of the research
process (Holloway and Freshwater, 2007). This reflectivity helped to recognise
relationships with the participants; in this case some had been students and some
worked on areas where the researcher was the educational link with the university,
therefore a previous relationship already existed. Also, the recognition of personal
responses to some of the incidents discussed generated comparisons with the
professional experiences and values of the researcher. The researcher’s own
experience had resulted in a limited personal understanding of the contribution
nurses make to the addressing of ethical dilemmas in practice and, therefore, care
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was taken to recognise this. The researcher’s personal experience as a nurse also
influenced the aim of the study.
Peer review experts in the field
The results of the study and the transcripts of interviews were discussed within
supervisory sessions (Long and Johnson, 2000). Both supervisors were registered
nurses and experienced researchers.
The pilot study and provisional findings were presented and discussed at a
European Doctorate Students Research Conference. The abstract and a copy of the
PowerPoint presentation can be viewed in Appendix 8. This provided the opportunity
to discuss key aspects of the study (Long and Johnson, 2000).
The study was reviewed at key progression points through the life of the study, which
included the critical review of the study design, data collection and preliminary
findings by a group of internal panel members selected by the University of
Huddersfield research department. This also provided the opportunity to discuss any
amendment that might have contributed to improving rigour (Long and Johnson,
2000).
A keynote presentation was undertaken at the Undergraduate Student Research
Conference for the Department of Health Sciences. This was attended by both
academic staff and undergraduate students who were given the opportunity to
question and discuss the points raised within the presentation. (see Appendix 9).
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Aspects of data collection
The sampling frame was designed so that appropriate participants were recruited.
The purposive approach helped to ensure the recruitment of participants from a
range of backgrounds with differing types and length of experience (Gerrish and
Lacey, 2006).
The audio taping of interviews for transcripts was undertaken to ensure accurate
records were maintained (Polit and Beck, 2008).
3.4 Summary
In order to address the aims and objectives of the study a qualitative design has
been adopted to undertake semi-structured interviews with 11 nurses from a
secondary care context. Themes emerging from the analysis will be explored in
Chapters 4 -9.
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Chapter 4- Results
4.0 Results: Demography and Introduction to Findings
Chapter 4 presents detailed demographic information about the participants who
completed the interviews and introduces the initial themes, which are fully critically
presented in separate chapters.
4.1 Participant profile
The participant profile summarised in Table 1, Chapter 3, shows that the sample
included nurses with a variety of different experiences. The summary does not
indicate the participants’ educational profile or gender; the reasons for this and the
impact this has on the results are discussed further in Chapter 11, Limitations to the
study. All but one participant were female; the male participant has not been
identified in the Table below to help maintain the anonymity of the participants.
4.2 Results of thematic analysis
As explained in Chapter 3, thematic analysis of the interview transcripts was
undertaken followed by theoretical analysis. Prior to analysis all participants were
allocated a non-gender specific name. The term `charge nurse` is used for both
charge nurses and ward sisters. Where direct quotes from participant transcripts are
used they are presented in single spaced italic font with the participant’s pseudonym
alongside to indicate which account it has been taken from.
Each of the complex accounts contained several key themes and subthemes. These
are discussed in detail in Chapters 5 – 8. The themes were developed throughout
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the process of analysis. Analysis of the pilot data resulted in a broad number of
themes:
Feeling
Rationale for decision-making
Personal Responsibility
Outcome
Beliefs and Values
Problem Identification
Conflict and Collaboration
Compromised practice
Action
Accountability
Policy.
Following thematic analysis of all the interview data these initial themes were further
developed into themes and sub themes. The main themes and subthemes are listed
in Table 2 below.
It was evident from all the accounts that the patients’ best interests were at the
forefront of nurses’ decision making. However, nurses identified that there were
constraints on their decision-making and action as they took into account the needs
of others. The impact of any decision regarding one patient’s best interests on others
in their care and issues in relation to national and local policy had the potential to
limit resources within the context of their practice.
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Table 2: Themes from the thematic analysis
Results for each of the main themes are discussed in the sections below:
Best for the patient: (see Chapter 5).
This section includes an examination of participants’ accounts where they expressly
talked about how they strove to achieve the best outcome for the patient and where
they adopted the role of advocate and they explained how they strive to maintain or
improve standards of patient care.
Accountability: (see Chapter 6).
Participants’ accounts articulated their personal or professional accountability.
Although not all participants referred directly to accountability, each participant
Tree code Sub code Final Free codes
Best for the patient Advocacy. Standards of care
Values Determination
Accountability Autonomy Duty Actions
Problem identification
Collaboration and conflict
Nurse Manager Doctor Patient. Patient relatives. Other health care professionals
Resources Policy
Concern for others Nurse Manager Doctor Patient. Patient relatives. Other health care professionals
Professionalism Consequences
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expressed a willingness to justify their decision to whoever wished to question or
challenge it.
Professionalism was identified as influencing the way in which nurses behave; when
participants felt that other nurses had not behaved in a professional manner this was
seen as a cause for concern, as discussed by both Sam and Drew in their accounts.
Collaboration and conflict: (see Chapter 7)
Collaboration and conflict were identified within all the participant accounts. This
helped to bring understanding to the context within which these nurses work and the
importance of the relationships between themselves, the patients and their families
and other health care professionals. Nurses’ relationships with others appear to have
a strong influence on the contribution nurses make to resolving ethical dilemmas.
Concern for others: (see Chapter 8)
Throughout the interviews participants expressed a strong duty of care to their
patients. However, the analysis contains evidence that although what is best for the
patient is foremost in their minds and decision making, the impact of this on other
people, including other patients, patients’ families and other health care
professionals, is also a consideration.
Charlie’s story (see Chapter 9)
This chapter presents on ethical encounter, in context, discussed by Charlie, an
experienced staff nurse who was charged with selecting a patient to be transferred to
a non-specialist area so that an acutely unwell individual could be admitted to the
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specialist ward. In Chapter 9 themes are highlighted and some of the theory
underpinning Charlie’s decisions and action. The most important aspect of Chapter 9
is, however, to identify and explore where the relationships are developed and how
they impact on the nurse’s ability to contribute to both ethical decision-making and
undertaking moral action. This contributes to a re-conceptualisation of the theoretical
framework outlined in Chapter 1.
This chapter has detailed the profile of the participants and initial themes; the
following Chapters 5 – 8 present the results of the thematic analysis.
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Chapter 5 - Best for the patient
The participants were asked to reflect on an ethical dilemma in practice; all of them
explained how the dilemma they were facing impacted on patient care and it was
often this that was the driver behind the decision making and actions they took. The
interest of patients was an overriding theme and clearly at the forefront of their
thinking when faced with ethical dilemmas. The participants talked at length about
how they strive to meet the needs of patients and maintain standards of care whilst
respecting individual patients’ wishes. Participants clearly articulated and were
passionate about that which they understood to be in the best interests of, or ‘best
for’, the patients. Although this may appear paternalistic, it is evident from
participants’ detailed accounts of their actions that this was not the case.
Chris explained how, when faced with the complex discharge of a patient, the
nursing contribution was informed:
‘It's knowing, I don't know it's your conscience isn't it? Knowing that if he did go home that he'd end up in the same position or worse, or dead, you know. It's massive, you know, you wouldn't want that for anyone. You wouldn't want that for your own family would you, so.... It's like being an advocate for somebody and getting the best and it would have been easier to do that, but it's not always the best thing for the patient is it?’ Chris
Ross concluded that :
‘I have had a few ethical dilemmas at the end of the day I always considered the patients was uppermost and that justified my position’ Ross
Ross and Chris demonstrated the ways in which all of the participants explained how
the principle of ‘best for the patient’ guided them to advocate for patients and
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promote patient autonomy. The next section demonstrates how they understood
patient autonomy and how the nurse’s role as advocate facilitates achieving what is
best for the patient.
5.1. Advocacy
Advocacy influences the standards of care received by individual patients; those who
are able to be autonomous can speak for themselves, but where appropriate, an
advocate should be identified and empowered to influence decisions making
regarding treatment and care (Hawley, 2007). Many of the participants explained
how they advocated for patients and promoted patient autonomy.
Advocacy is the support for a person or cause; in this case it is patient advocacy as
the nurse supports patients’ wishes and assists in self-determination, promoting
autonomy (Hyland, 2002). Autonomy is linked to dignity in that the ability to maintain
one’s dignity is influenced by the amount of power or control one has over the
situation (Hyland, 2002). This is not to say that those who lack capacity to make
autonomous decisions do not have moral worth [as perceived by another and felt by
the individual], as such, they should be treated with dignity (Gallagher, 2004).
Advocacy is not, however, a simple process of representing the patient’s wishes.
The patient’s capacity to make decisions and the nurse’s role as advocate have to
be considered within the nurse’s duty of care and the impact the decision and
consequential actions may have on others (Hyland, 2002).
Chris’s account of a complex discharge home, in which a patient’s capacity to make
a decision was assessed as a ‘best interest decision’ (MCA, 2005), illustrates the
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nurse’s role in advocacy. Chris felt that the patient did have capacity; the family
however felt that he did not. Chris, to be sure of the patient’s level of capacity and
recognising that the family might know the patient better than a nurse did, decided to
contact the social work team to assess the patient’s capacity.
‘People jumping in and making the decision for him, I didn't want that to happen that's why I pushed for a Best Interests Assessment,’ Chris
Best Interests decisions have been defined within the Mental Capacity Act (MCA,
2005) as ones which take into account the patient’s beliefs and values, if known, and
where possible the patient must be encouraged to be involved in the decision
making process. The least restrictive option is the preferred option; that which is
going to cause least disruption or conflict with the patient’s wishes or what his wishes
would be if able to engage fully with the decision making process (MCA, 2005). In
Chris’s account the patient was considered to be vulnerable when in his own home
and therefore re-housing was an option he and the health care team could consider.
In this situation, the action undertaken by Chris promotes patient autonomy by
advocating for the patient, providing information, involving social services and
ensuring the patient was aware of the options. Chris ensured the patient was
involved in the decision making as far as possible even though the assessment
indicated that he did not have capacity to make his decisions independently in this
particular situation.
‘I don't think he realised the other things that could happen, he could be re-housed, he could go to short term accommodation while he waited to be re-housed, things like that, so I don't think he fully understood his options’. Chris
In an examination of the two concepts of, patient autonomy and patient advocacy
Hyland (2002) suggests that advocacy is not a role that belongs uniquely to nurses.
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It does, however, as demonstrated through the participant accounts, form part of the
nurse’s role. To advocate for an individual patient in this context includes
representing them in case conferences or promoting the patient’s autonomy by
ensuring they have all the facts and understand the implications of their decisions.
Advocating for the patient may include defending a patient’s informed decision even
where this may appear unwise (Hyland, 2002).
In Chris’s account the patient initially wanted to go home, whereas the patient’s
family and the health care team felt he was vulnerable to abuse from neighbours and
local youths, as there had been incidences in the past. By simply accepting the
decision Chris might have failed to fulfil the duty of care that nurses and other health
care professionals have (Dimond, 2008). Alternatively, as Chris expressed above, it
would be equally wrong for others to take all control and make decisions for the
patient without his involvement. The conflict between promoting patient autonomy
and maintaining patient safety engaged Chris’s ‘conscience’, as going home involved
a risk to this patient’s welfare and was potentially harmful to him and this raised
concerns about his capacity
Although Chris felt the patient had capacity, he recognised that the patient did not
fully understand the situation, possible outcomes and what options were available to
him. Verkerk (2001) explores what he describes as ‘compassionate interfering’ or
‘rational autonomy’ in caring relationships. This has become topical in the
Netherlands as care is becoming increasingly delivered in the community, as it is in
the United Kingdom (Darzi, 2008). The risk is that those who are most vulnerable or
96
wary of the health and social care system fail to receive much needed care (Verkerk,
2001).
Duty of care is the duty a nurse has to protect patients from harm and promote
independence; patients should be no worse off after receiving nursing care than they
were beforehand (Cuthbert and Quallington, 2008). Decisions need to be made on
an individual basis dependant on the patient, the situation and the level of risk. The
Code (NMC, 2008) requires nurses to advocate for people in their care, supporting
them to access information and services, emphasising the importance of respecting
their choices and preferences by listening to their concerns (NMC, 2008).
Minimising harm and risk are also addressed within The Code (NMC, 2008) requiring
nurses to practise using the best available evidence and to report if a patient has
been or is at risk of harm.
Chris had clearly listened to the patient and his preferences, identifying that although
he appeared to have capacity and though his decisions might have appeared
unwise, they were his preferences. Working with the multi disciplinary team and the
patient’s family, there appeared to be doubt about his capacity; therefore an
independent advocate was engaged to support the patient. Collaboration is
discussed further in Chapter 7.
Chris recognised personal limitations within this situation and was supporting the
patient’s rights and respecting the patient’s choices, both of which are required of the
nurse within The Code (NMC, 2008). The patient’s capacity, in this case, to make
decisions was compromised and his understanding of the situation was limited.
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When fully supported and informed the patient chose to be re-housed, a decision he
felt happy with; the risks to him had been reduced through re-housing in a safer
locality.
‘His daughters were happy, he was happy, I was happy, Social Services were probably happy.’ Chris
Thus, although Chris was initially unhappy with the proposed course of action, the
process of negotiation, discussion and assessment of capacity led to a decision that
was acceptable to all and, most importantly, respected the patient’s right to make his
own decision. Advocacy is understood as representing the patient’s viewpoint,
values and beliefs (Cuthbert and Quallington, 2008).
Advocacy can become more complicated when caring for children. In an account
shared by Ashley, a children’s nurse, caring for a young teenager, Ashley had to
make tough decisions about how to best advocate for a patient. Ashley described
how nurses need to balance disclosure, the patient’s vulnerability, requests for
confidentiality and the risk of jeopardising family relationships (especially the impact
this will have on the child) in relation to concern for the child’s welfare.
‘........you might talk to the child and try and sort of get them to 'you really need to talk to your mum about it and ......sometimes it works and sometimes it doesn't........ you have to make that decision, and again it comes with experience and with age.....’ Ashley
In the United Kingdom there is no single piece of legislation that covers child
protection so, for any nurse working with children, not only will they need to consider
if the decisions are ethically sound but also how the law impacts on this. The main
piece of legislation is the Children’s Act (1989) which clearly states that the child’s
welfare is of paramount importance. The Children’s Act (1989) recognises that each
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case needs to be considered individually with this in mind and to assist
understanding it defines both ‘harm’ and ‘significant harm’. The National Society for
the Prevention of Cruelty to Children (NSPCC) has produced guidance for those
working with children, drawing together all the legislation and guidance in a single
document (NSPCC, 2012).
It was evident from Ashley’s account that less experienced nurses lacked the
confidence to make some of these decisions, whilst still recognising the importance
of these issues. When caring for a teenager whose mother appeared to be
particularly influencing her daughter, doubts were raised about the possibility that the
account provided by the mother had led to unnecessary procedures being
undertaken. Less experienced nurses consulted those with more experience:
‘younger girls [Nurses] who were working with it found it really difficult. You know, and that's probably why I know about, because they'd come and talk to us, you know the senior staff.’ Ashley
The idea highlighted here by Ashley is that nurses are able to develop the skills
required to advocate, especially in complex situations, through clinical experience
(Kohnke, 1982).
Care of the dying was identified as another complex area of practice where
participants viewed their role as advocate as important and necessary. Both Jo and
Charlie identified instances when they attempted to advocate for patients at the end
of life. Both explained how the surgical team gave instruction to administer active
curative treatment, which was felt by the patients’ families and the nurses caring for
these patients to be futile. Jo and Charlie expressed the opinion that the care of the
dying pathway should be initiated sooner to facilitate a more dignified, peaceful and
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pain free death. Jo persisted with attempts to advocate for patients for some time
before the care of the dying pathway was commenced.
‘called the registrar and the plan was to carry on for a further 24 hours of active treatment and see from there, but as the day went on the patient continued to deteriorate her breathing, more shallow, so what I did was I got a big consultant up who decided that really the patient was for care of the dying pathway, but from start to finish when they start you know.... 7 o'clock in the morning we doing this all the way up to 4 o'clock in the afternoon.’ Jo
Field notes indicated that both of these nurses felt passionate regarding the delay in
commencing the care of the dying pathway and felt that had this been commenced
earlier, the end of life experience for both the patient and family could have been
less distressing. This was evident in the way their accounts were articulated.
Also noted was the level of concern that remained with nurse participants in relation
to this issue:
‘but you know for the patient I thought it wasn't fair on the patient, he should have been with it, I don't think she would have wanted to have all what she had done to her, and her daughter didn't really either. Her daughter was saying 'I just want her to be comfortable' Jo
Charlie agreed when discussing care of the dying patient concluding:
‘I just feel that sometimes they're too late, do you know what I mean? And it was awful, the family were there and the man was in pain and we couldn't get on top of him, his chest was poor and we were struggling all day and we gave him everything, and I felt we'd done as much as we could but we were too little, too late.’
Charlie
The comments made above by Jo and Charlie reflect the literature reviewed in
Chapter 2 concerning moral distress. Nurses here have expressed how they felt
about the situation where their preferred course of action was delayed and although
they expressed their opinions in relation to patient care, they were still required to
continue with active treatment for longer periods of time than they considered to be
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appropriate (Oberle and Hughes, 2001; Dierckx de Casterle, et al., 2010; Long-
Sutehall et al., 2011).
Participants working in intensive care units identified that the withholding and
withdrawing of treatment presents nurses with personal and professional challenges
as they strive to advocate for and provide care for the dying patient. Nurses often
have to contend with conflict with the doctor who may have a different care
philosophy (Halcomb et al., 2004).
When nurses feel they fall short of their responsibilities in advocating for patients and
ensuring the best care provided for the patient, residual moral distress may occur
(Corley, 2002). Nicky, who was trying to manage the clinical area with limited
resources, highlighted the feelings experienced when managers were asking for a
nurse to be sent to another area, leaving the unit understaffed.
‘I felt like no-one was listening. Like I come on duty and try and you know
you're patients advocate.’ Nicky
Nicky’s account was full of passion for what was felt to be the right thing to do in
order to maintain standards of care and the situation.
‘So yes I do feel quite passionate, and that day really brought it home to me how let down I felt by my own workforce as a nursing establishment.’ Nicky
Conflict which occurred in all these cases is discussed in Chapter 7.
5.2. Standards of care
The second subtheme related to ‘best for the patient’ is standards of care. The
importance of maintaining high standards of care, as articulated by participants in
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their accounts, is also recognised in the literature. Nurses cannot maintain standards
of care alone as they work within the wider context of health and social care (Maben
and Griffiths, 2008). Nurses do, however, have a valuable contribution to make
(Maben and Griffiths, 2008), and thus collaboration is discussed in more detail in
Chapter 7.
Quantitative targets, such as reducing accident and emergency waiting times,
treatment waiting times and the reduction of surgical waiting lists (DH, 2000) and
treatment time-lines such as those introduced in The Cancer Plan (NHS, 2000) and
The National Stroke Strategy (DH, 2005), continue to be important, however, a
change of emphasis has occurred following High Quality Care for All (Darzi, 2008).
High Quality Care for All (Darzi, 2008) acknowledges the improvement in waiting
times and recommends a focus on quality and the importance of improving
standards of care. The importance of high quality care has been further highlighted
as one of six principles of the NHS Constitution (DH, 2012); qualitative measures are
now recognised as indicators of care standards.
The importance of maintaining standards of care was clearly articulated by all the
participants. Charge nurse Sam explained how continued monitoring and support for
the development of a particular member of staff was facilitated. This was required as
the staff member was not behaving in an appropriately professional manner and not
providing the standard of care that was expected by the patients, the Trust and the
nurse’s colleagues on the ward.
‘I was dealing with that on a regular basis. I would make her aware that I knew that she had been leaving duty early when I wasn't around, that she'd said
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something inappropriate to a patient or member of staff and that her whole demeanour was, .......I expected her to keep the ward functioning in the way that we'd worked hard to get it to and that if she had issues with that we could openly discuss them. I had regular meetings with her, we met and I put objectives into place for her, she had an induction check list and I was constantly reminding her of things that she needed to do...’ Sam
Sam’s account clearly demonstrates the efforts, energy and emotions that were
involved in addressing these problems and supporting the struggling nurse to
develop appropriate skills to ensure that standards of care were maintained. The
importance of maintaining standards of care in the ward environment remained of
utmost importance to Sam. Sam explained what was happening and the concerns
that arose:
‘There was a lack of professionalism about her, that existed in things, calling people 'chuck' and 'love', and referring to me as 'chuck' and things like that, and then as she gradually settled in during the coming months I'd hear the odd swear word mentioned on the corridor and things like that and a change in the nursing staff.... they behaved much differently around her than they did me, .........’ Sam
Nurses are required to provide a high standard of care, as indicated in The Code
(NMC, 2008). Providing this standard of care involves using the best possible
evidence and treating those within the nurse’s care as individuals and working
collaboratively, upholding the reputation of the profession. Failing to do this, the
nurse described by Sam was putting standards of care at risk, and jeopardising the
‘best for the patient’ ideal. Sam explained how efforts were made to maintain
standards of care on the ward:
‘it was like having to work without all your tools and deliver a critical job without all your tools. You knew that when she was looking after a group of patients they wouldn't get the standard of care that they needed, and I was responsible for improving that and the dilemma I’m under is that pressure and that feeling of constant 'I wonder what she's doing today while I’m not there?', 'has she got this right, do I need to check that?' Sam
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Nurses form part of the service delivery team and have a key role to play in ensuring
standards of care are maintained and targets achieved (Maben and Griffiths, 2008).
This can prove challenging especially when resources are limited (Ulrich et al., 2010)
In Jordan’s account, the loss of a nurse specialist had led to care standards being
under threat and this had led Jordan to begin developing personal skills and ward
resources to support patients requiring care on the ward.
‘...we've not had the funding to replace her. But apparently there are not many places that have, because me and my colleague are wanting to do some more information for the amputee patients.’ Jordan
Shortages of nursing staff have been identified as one aspect of the secondary care
context that causes a significant amount of stress for nurses because of the negative
impact this can have on standards of care (Ulrich et al., 2010). Sam explained that
developing standards of care for patients is one of the main functions of a charge
nurse responsible for clinical care:
‘...developing this area for the benefit of the patients and staff until I retire, so you know it isn't one thing’. Sam
Charge Nurse Brooke described how problems related to pressure area care were
highlighted as national standards and local policy led to changes in the classification
of wounds. When the number of wounds of a specified classification rose on the
ward above what was felt to be acceptable according to Trust policy, remedial
measures were then implemented. The nurses on the ward felt this implied that
patient care was below the required standard and this impacted negatively on staff
morale. The account shows how Brooke worked to balance complying with local
policy to reduce the occurrence of pressure ulcers on the ward with ensuring national
standards were maintained and recognising the hard work undertaken by the nursing
team in order to preserve staff morale.
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‘I’ve also talked to all the staff as well and I’ve said 'actually you're very highly thought of', and in fact two of the managers have been on the ward and have been really, really supportive of me as well now, because they realise how sort of passionate we are about it and how we just don't want this to happen’.
Brooke
Staff morale is linked to standards of care. Where staff shortages have impacted on
the standards of care nurses are able to provide it has a negative impact on staff
morale (Nolan et al., 1998; Adams and Bond, 2000; Day et al., 2007). Brooke
identified how attempts were made to empower staff and to give them a voice,
reinforcing the value placed upon their contribution to care, in an attempt to improve
staff morale (Faulkner and Laschinger, 2008):
‘They did a staff survey .........my matron got in contact and said 'we need to send somebody to actually speak to the Chief Executive and she's organising some forums'. And initially I was asked to go but I was teaching (I do like to do a bit of teaching still), so I was actually teaching urology and couldn't go, and so they let me off but asked for staff to go on it, now I’ve been talking to other sisters on other wards and they're going themselves and I don't think that's the issue, I think it should be the staff members on the ward.’ Brooke
Nicky, an ICU (Intensive Care Unit) Charge Nurse, described how the Charge Nurse
makes decisions based on the assessment of the clinical area in order to ensure that
the standard of care delivered on the unit is of a high standard, maintaining patient
safety. In this case shortages of staff on another unit had resulted in the Matron
contacting Nicky and directing one of the staff nurses on ICU to be moved to a ward
area where there were insufficient staff:
‘I’m not going to do that just because she says so. I’m an individual with a mind of my own and they've put me in a responsible position to stand up and be an advocate for patients and that's what I’m doing.’ Nicky
In this instance Nicky was refusing to move staff to ensure patients on ICU received
the standard of care they needed.
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Nicky not only relied on professional judgment but justified the decision by referring
to national guidelines provided by the National Institute for Health and Clinical
Excellence to provide a rationale for the decision. Policy and its impact on nurses’
contributions to the resolution of ethical dilemmas will be further discussed in
Chapter 7.
Lee described making the decision to keep a frail elderly patient in his current
location and administer what Lee described as the ‘second choice drug’, rather than
putting the patient through the stress of travelling in an ambulance to another site.
‘My thoughts behind it were I wanted to do what I felt was best for the patient.’ Lee
This had been a difficult decision as Lee had weighed up the benefits and burdens of
two courses of action. One option was to administer the ‘second choice’ drug which
might not have been as effective as the one Lee would have preferred to administer,
which was not prescribed. The other course of action was to book transport, in this
case an ambulance, to take the patient to the main hospital site where the doctor
would be able to review the patient’s medication and prescribe a drug which could
potentially bring more relief than the ‘second choice’ drug. Neither option was
considered to be ideal. When reflecting on this decision and the action taken Lee
explained:
‘It left me thinking had I done the best for my patient. It left me thinking did I
give the patient the best I could have given her’ Lee
Nurses aim to deliver the best possible care and, as explained by Lee, this informs
both decision making and the consequential actions.
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Jordan, an experienced staff nurse, was concerned about how news was delivered
to patients and the information they were given regarding the amputation of lower
limbs. Jordan explained how the nurses on the ward were trying to change practice
in order to promote patient autonomy, especially when decision making regarding
treatment options. Jordan wanted to ensure that patient care was at its best,
particularly psychological support, prior to making the decision to proceed with
surgery, in adapting to their new body image and changes in their life style.
‘You try and talk to the patient you know and explain that things are sort of
there to help them if they do go ahead with the amputation and you know if you don't go ahead with the amputation you do realise what's going to happen and sometimes you can't change a patients mind and it's just a case of supporting them through that decision that they have made and trying to make them as comfortable as you can.’ Jordan There is evidence that nurses strive to achieve high standards of care and feel that it
is a priority for them as nurses. There are also numerous policy directives from the
Department of Health (DH, 2008; Francis, 2013) and regulations from the Nursing
and Midwifery Council which also emphasise the importance of care standards
(NMC, 2008). Complaints continue to be received and reports written demonstrating
that this is not always the case and, in some instances, patients and their families
receive poor treatment from health care professionals and services. For example,
the Care and Compassion report (Parliamentary and Health Service Ombudsman,
2011) highlighted ten cases which demonstrated how patients and their families had
been let down by health care professionals. The report identified how it is often those
patients who are most vulnerable who fail to receive appropriate care (Parliamentary
and Health Service Ombudsman, 2011). This may be due to their complex needs,
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compromised ability to communicate effectively or poor co-ordination between health
care professionals and services.
Issues of poor care standards and failure to respond appropriately have recently
been highlighted in the Report of the Mid Staffordshire NHS Foundation Trust.
A Public Inquiry found that failings both of the Mid Staffordshire NHS Foundation
Trust as an organisation and of individuals had resulted in unacceptable standards of
care for patients within the mid Staffordshire NHS Hospital Trust (Francis, 2013).
For Sam, the complaints received from patients’ families and staff on the ward
informed the decision to take a more serious approach to managing the nurse who
had put standards of care at jeopardy.
‘really wrestling with it and found it really quite difficult, but as more time went
by situations worsened and worsened and complaints started coming in about her from the staff, complaints started coming in about her from relatives and patients.’
Sam
The complaints were related to standards of care and, despite Sam’s best efforts to
support the nurse involved to develop her practice to ensure that high quality care
was received by patients on the ward, things did not improve. Finally, Sam had no
choice but to refer this to a competency assessment and the nurse left the ward.
‘Complaints were in relation to either standards of care or attitudes ............. I
worked through the complaints and involved her completely with them all the way, interviewed her, lots of denials....................it was just all cover-up really from her point of view, probably that she was panicking as well at that point and all the time right up to the end I supported her and always tried to help her and she'd got no idea whatsoever not one smidgen of an idea of how I felt,’ Sam
Sam’s account demonstrates that putting effort into ensuring that the staff and the
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team are appropriately skilled and always present themselves in an appropriately
professional manner is important, however the patient takes priority and care must
not be compromised.
5.3. Conclusion
The theme ‘best for the patient’ and the subthemes of ‘advocacy’ and ‘standards of
care’ appear to be one of the most important aspects for nurses when making
decisions about patient care and were felt by participants to be paramount when they
were confronted with ethical dilemmas. ‘Best for the patient’ was the first priority
every participant referred to in their account. This is also supported by The Code
(NMC, 2008) and is also a major theme in the review by Lord Darzi, High Quality
care for all, (Darzi, 2008) identifying that the next stage for the National Health
Service is to progress from a quantity focused agenda to one which focuses on
quality. Chapters 6 to 8 will now explore other themes from the data.
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Chapter 6 - Accountability
6.0 Accountability
The participants did not all refer directly to accountability within their accounts.
However, when analysing their interview transcripts it was possible to identify that all
participants were aware of their accountability. The participants’ awareness of
accountability as a responsibility that may be punitive or supportive of action sheds
further light on factors affecting ethical decision making. Within accountability the
sub-category of nurses’ autonomy emerged, which is discussed in section 6.1 below.
Two of the participants referred directly to accountability. The type of accountability
was not specified by the participants. The incidents discussed fell under several
types of accountability: ethical, professional, legal and employment (Caulfield, 2005)
Brooke shared an experience from early practice in which a drug error occurred. In
the incident described the error was a prescription error. The prescribing doctor
made the error when writing the prescription but only the nurse who administered the
drug was held accountable. The drug error was reported, according to The Trust
policy, and no harm came to the patient. From Brooke’s perspective, the burden of
responsibility appeared to fall solely on the nurse. Brooke felt it was unjust that only
the nurse involved at the point of administration was held to account for the error:
‘I was honest about it, yes, and I actually went through the proper process, but I just felt that the way it was handled was really negative and it was.... and I mean I know we're all accountable, it's accountability and responsibility isn't it? But some other people were responsible I felt.’ Brooke
There are processes which every prescription undergoes before administration,
including the writing of the prescription, which is checked and dispensed by a
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pharmacist and, on this occasion, the drug was also checked by a second nurse at
the point of administration. The dilemma here is who was responsible and that, by
holding only the nurse accountable, it felt unjust. Brooke recognised the nurse’s
accountability. However, Brooke also viewed others within this incident as having
some responsibility, as not only did the doctor prescribe an incorrect dose, checks
built into the process to reduce the risk of drug errors were undertaken by the
pharmacist, who ensured the drug had been prescribed and checked for drug
interaction. Each of these individuals belongs to a profession with a code of conduct
which indicates their professional accountability for their actions. Accountability and
a code of ethics are viewed as hallmarks of a profession (Hood and Leddy, 2006).
This experience has influenced the way Brooke manages drug errors within the
clinical area. Brooke explained the importance of ensuring that, whilst those who
make errors are held to account, ‘blaming’ one individual is not the best way. Brooke
recommended a review of the incident and that measures to reduce the risk of
repeated errors should be identified and implemented. The use of professional
codes as punitive measures may result in a reluctance to report errors by nursing
staff, which may impact on the quality of care. Professional codes should be used to
facilitate dialogue and provide a standard to work to (Esterhuizen, 1995). Brooke
viewed this as part of the charge nurse’s role, as the charge nurse is responsible for
maintaining safety and standards of care in the clinical area. Brooke took the
welfare of the ward staff seriously; this is explored further in Chapter 8.
Drew also referred directly to accountability in relation to a drug error. In Drew’s
account the error took place at the point of administration; the nurse who made the
error was an agency nurse who did not normally work on the ward in question. The
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issue for Drew was not so much the error itself but the way that the nurse who made
the error acted subsequently. The agency nurse [who made the drug error] did
inform the doctor and the nurse in charge of the ward at that time but refused to
inform the patient:
‘So then it was left for myself and some other members of staff to then explain the procedure to the patient. So then it is not necessarily my accountability, I suppose its more her accountability but I had to intervene because to me she just did not recognise that area of her accountability. She [the nurse who made the error] felt it was important to follow certain procedures in terms of the medical side of things but as to informing the patient and maybe the relatives it wasn’t considered important’. Drew
Drew explained the feelings this evoked:
‘Well I felt shocked that she did not feel this was important despite being an experienced nurse even though she was from the agency and her argument was well I am from an agency and it doesn’t matter. To me she [the nurse who made the error] is a registered nurse and she is accountable to the patient regardless of where she is practicing umm… So I was very frustrated by the whole thing and worried. I could not understand we had offered support for her and everything, but she seemed to totally disagree that the patient should be informed. I found her response at leaving the ward in ...well I would say it was a strange really. Umm… just to dismiss all her responsibilities having given a patient the wrong drug.’ Drew
Drew felt strongly about nurses’ responsibilities and accountability to the patient. In
referring to professional accountability Drew emphasised ‘as a registered nurse’,
indicating that the nurse had failed to fulfil her responsibilities to the patient by
explaining that an error had occurred. Drew’s conviction to uphold the patient’s
rights resulted in her fulfilling the responsibilities of the nurse who refused to discuss
the error with the patient. Where there is a right, someone, in this case the
administering nurse, has a duty to uphold those rights (Beauchamp and Childress,
2001). In Drew’s account, for instance, the administering nurse had only partially
fulfilled her duties as she had refused to inform the patient of the error. The nurse
[who made the error] could be held to account to the patient, for failing to respect her
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rights, to the employing organisation, as she has failed to follow The Trust
medication error reporting policy fully and to the profession, as The Code (NMC,
2008) specifies that, as a registered nurse, she must be open and honest at all
times. A nurse must also protect and promote the health and wellbeing of their
patients. In this case the administering nurse who did not fulfil these duties was
professionally accountable for her omission (NMC, 2008). Accountability may be
viewed as punitive, as indicated above. The negative connotations associated with
accountability emerged in the 1930s when fewer nurses worked in private homes
and began to work for larger organisations. Nurses began to view the organisation
in which they were now employed as accountable and the view that accountability
was a disciplinary tool emerged (Hood and Leddy, 2006).
When nurses’ actions are placed under scrutiny by the NMC during professional
conduct cases it is The Code (NMC, 2008) which is the standard against which a
nurse’s conduct is judged. Accountability, however, can be empowering, as
demonstrated in participants’ accounts below.
Alternatively, accountability can be used to motivate. To be accountable can help to
promote good practice and motivate good actions, especially where the professional
boundaries are blurred (Savage & Moore, 2004). The hierarchical culture within
health care can influence the decision making process; whilst it does not relieve the
individual of all accountability, the position held within the hierarchy impacts on the
influence and authority members of the team have in any given decision making
situation (Hood and Leddy, 2006). In Drew’s account below the Charge Nurse had
instructed Drew to administer sedative medication to an elderly patient. The drug
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was prescribed as a ‘when required’ medication to be administered by a registered
nurse when or if the need arose. In this account Drew explained how personal
responsibility and professional knowledge informed her decision making and
consequential action:
‘And I was responsible for looking after the patient, so I decided to make the decision not to give the drug ....................I felt confident at that time I could justify why I was not going to give this patient the drug ‘cos I didn’t feel this patient needed the drug at that moment in time and that I disagreed with his [the charge nurse] reasoning I suppose if you like of why I should give the drug’. Drew
The Charge Nurse was Drew ’s line manager; Drew did not follow the instruction but
considered her responsibility to the patient and acknowledged her accountability to
the patient in declining to administer medication that was felt to be unnecessary
based on Drew ’s own assessment of the situation.
6.1. Autonomy
Examples of nurses undertaking autonomous decisions informed by their own
knowledge and understanding of the situation were described by participants. Some
of the interview transcripts gave accounts of how some of the decisions made were
contradictory to the judgments of other health care professionals, senior nursing staff
or The Trust policy in a given situation. In each case the participant understood their
rights and responsibility to act with autonomy, was able to justify the rationale for
their decision and was happy to be called to account.
Sam was motivated to strive to improve standards of care on the ward by investing
time and energy in the professional development of a nurse from the ward team.
‘what I did was I’d set some objectives for her as well to improve on two
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occasions in one year............... I very much left to do my own thing with her really, everyone was aware, but I knew that Associate Director of Nursing and the Matron trusted me to manage her and that was nice to feel that I could be trusted so I felt it was imperative that I dotted the i's and crossed the t's as I would with any member of staff on the ward going through the same thing,’ Sam
Although Sam explained how the situation was managed, he was required to make
decisions about the approach used to support the staff nurse’s development and
what strategies to use when the situation became unacceptable. Sam felt that the
senior nurses, who were also her managers, were supportive of those decisions on
the whole, trusting her and respecting her autonomy as a nurse.
Ross, however, did not feel supported when asked to transfer patients into the
discharge area to await hospital transport to take them home; this is an area where
they are no longer classed as acutely unwell or in need of hospitalisation. When the
Bed Manager, whose job it is to ensure patients flow through from accident and
emergency or other admission routes swiftly to an appropriate ward base, requested
that two patients be transferred to the discharge lounge to await their transport
home, Ross did not feel that moving the two patients was appropriate and was able
to explain why. Here Ross was demonstrating both an ability to make autonomous
decisions and the preparedness to be called to account for decisions and action.
‘Yes they might feel comfortable back in their own environment once they got home. But we muddled them just by moving them for that short time in between. But the main one the main ethical dilemma for me was she wanted me to move a terminally ill man who was asleep in bed, who was actually going home to die. She expected me to get him out of his bed and sit him out so that she could move somebody else into that bed and I just found that no way umm…. and I said no’ Ross
‘they could have sent the chief executive on the ward I would have stuck to my guns and did what I thought was best for these patients. And I know that there were two other patients that were in need of a bed but I actually had to look after the
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patients that were there then. So, you know, it did make me question, even now, I feel I made the right decision’. Ross
In charge of the Intensive Care Unit, Nicky explained the role of the senior nurse as
advocate and resisted moving a staff nurse; within this account Nicky justified the
decision and recorded the rationale for the decision on an incident form. Nicky was
fully aware of the nurses’ responsibility in relation to patient care and safety on the
unit and was ready to be called to account for the decision.
Nicky explained that completing an incident form was in line with The Trust policy
which advises that the form be completed whenever a clinical area is thought to be
unsafe. Nicky was able to justify the decision and explained:
‘I wrote down every single patient on the intensive care, the care they were getting and why they needed one to one nursing. I wrote down about NICE guidelines, quoted NICE guidelines about level 3 patients which are ventilated and should have one nurse, but yes one nurse can look after two high dependency patients but I put down the constraints about how it was very difficult to help each other then, patient moves if somebody became sick, going for blood, things like that and just dealing with the everyday running of the intensive care unit by being a nurse down, and I don't know how far that incident form got, because I later got told along the grape vine that Matron tore it up, our Matron for intensive care and said that there was nothing they could do, we had to staff the overflow ward, there was no-one else could do it, we just have to see the bigger picture’. Nicky
Nicky presented a rationale for the decision not to move a nurse off the unit. This
decision was based on sound knowledge both of the needs of the patients on the
unit and the National Institute for Clinical Excellence (NICE) guidelines, which are
UK guidelines and thus hold more weight than organisational guidelines in publicly
funded UK hospitals (Caulfield, 2005). This indicates that Nicky acknowledged that
nurses also are accountable to The Trust (employment accountability) and to those
to whom they have a duty of care (professional accountability) should there be
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evidence of negligence (legal accountability) and Nicky had to consider the impact
on those involved and their intrinsic value as human beings (ethical accountability)
(Caulfield, 2005).
Nicky fought hard to maintain safety, was ‘over ruled’ by a more senior nurse and
was left feeling that the vulnerability of the patients on the unit had not been
recognised, nor had the senior nurse been prepared to fully consider the rationale for
resisting the loss of a nurse from the unit.
‘I said 'yes and I’ve got six ventilated patients and two that aren't, two that are really quite sick still. Who’s going to look after these while you take a nurse off me? What if something goes wrong on my shift? Who’s going to back me up? This is my shift.' So Matron then got involved and Matron came along and demanded that I send a nurse down to the overflow ward, so I was overruled and I had to send a nurse down to the overflow ward and consequently one nurse had to look after two ventilated patients, one of which was on the haemofiltration machine, which is like the dialysis. And obviously I was in charge of the unit and was looking after a ventilated patient as well, as well as trying to support members of staff and look after the patients’. Nicky.
Nicky felt that the ability to act autonomously is limited by the position held within the
organisation. The position of Charge Nurse did not hold sufficient authority in this
context to allow Nicky to act on the judgment made in relation to maintaining the
safety of the unit and fulfilling a duty of care to the patients on the unit. However,
each individual is responsible for their own actions and escaping accountability by
claiming to be acting on the instructions of another is not seen as justifiable
reasoning (Ormrod and Barlow, 2011). Applying Ormond and Barlow’s (2011)
interpretation, Nicky, the nurse manager who instructed the nurse to move to another
ward and the nurse who moved to the other ward based on the instruction of the
nurse manager were all accountable for their actions. For what each member of the
team is accountable will vary depending on the situation and level of authority held
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by the individual. In cases where health care staff have acted in accordance with the
organisation’s policy, the organisation holds some accountability with regard to the
outcomes of the applications of these policies (Hood and Leddy, 2006).
Nicky’s account demonstrates how accountability influences decision making but it
also illustrates the limits of personal autonomy, both with regard to the position held
and the context within which the nurse works (Hood and Leddy, 2006). There are
incidences when an individual’s autonomy is restricted in favour of that of the wider
community or society (Caulfield, 2005). It is possible that, in some cases, the
nurse’s preferred action to achieve the best for a particular patient conflicts with the
needs of others, therefore a compromise has to be found. In Nicky’s situation the
senior nurse had made the decision to reduce the staffing levels on the unit and was
therefore accountable for both her decision and the consequences of her actions
(Caulfield, 2005).
Accountability and autonomy can be seen to be inseparable; if a person acts
autonomously then that person must be accountable for that decision or action
(Hood and Leddy, 2006). Where a nurse has a responsibility to the patient which
requires autonomous decision making, the nurse may need the authority (or need to
take on the authority) to act accordingly (Hood and Leddy, 2006). This is not to
imply that nurses are not accountable for omissions where restrictions limit their
ability to act autonomously, for example where the nurse has no authority or when
availability of resources is limited (NMC, 2008). The nurse must strive to fulfil those
responsibilities as far as is possible given any limitations that may occur and needs
to demonstrate that everything possible has been undertaken to meet those
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responsibilities, including reporting shortcomings to a manager or person in authority
(NMC, 2008).
Lee’s account demonstrates how the decision to ‘bend the rules’ can be justified by
weighing up the benefits and burdens of each option to inform the decision making
process:
‘My defence would be that as a nurse my code of conduct and my ethics are that I do the least harm for the patient. And to me in that situation the least harm was leaving the patient where they were in a warm comfortable bed and taking the drugs over the telephone and giving the drugs. opposed to,....... I think, causing great harm and discomfort and distress, which could be quite detrimental when they are very poorly getting cold and uncomfortable banging over bumps in roads and being taken up to [the infirmary]. Where they might have to sit about in A&E for an hour waiting to see a doctor to go down and write up a script and see them. Then wait another hour or two for an ambulance to bump them all the way back again very very late at night’. Lee
It is evident that Lee knew that the action taken following the weighing of the benefits
and burdens of each course of action fell outside of the Trust’s usual policy and
acknowledged that acting autonomously and outside of the organisation’s policy
might leave those facilitating this action fully accountable; they would not necessarily
be able to look to The Trust for support through vicarious liability. In this case Lee
was able to take the preferred course of action only by collaborating with others who
had the authority to prescribe the required medication, facilitating Lee’s
administration of the drugs. Those who collaborated were also accountable for their
involvement in this incident (collaboration is discussed further in Chapter 7).
Risk was very much at the forefront of Lee’s mind whilst continuing with the chosen
course of action. Lee identified how there was an attempt to reduce the risk to the
patient.
‘… and getting a second colleague to listen to try and minimise harm and risk
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umm....But no I knew that you weren’t totally removing the risk as opposed to, I think, causing great harm and discomfort and distress, which could be quite detrimental when they are very poorly getting cold and uncomfortable banging over bumps in roads and being taken up to [the infirmary].’ Lee
From these accounts it is possible to see that the nurse participants felt able, if not
always empowered, to make autonomous decisions and were prepared to be called
to account for their subsequent actions. In these situations the participants felt
confident in their knowledge and understanding of the patients’ needs and the
situation in context. There is also indication that, whilst able to make judgments
about the situations described, participants were not always able to act as they
wished to. This, for some, resulted in feelings of frustration and of being
undervalued and disempowered. This was the case for both Charlie and Jo who
explained how, when caring for patients who were terminally ill, they recognised that
the appropriate time had come to instigate the care of the dying pathway; the doctor,
however, had another view. The doctor in both of these accounts continued with
curative treatments for what the participants felt was too long, before commencing
palliative care. Both Charlie and Jo expressed that they felt that this had made dying
more stressful for both the patients and their families.
Ross, having refused a direct instruction from the bed manager, explained the
feelings that this had generated:
‘....in a way it gave me numerous feelings because my values and beliefs are that this is somebody that is on a higher grade than me and you should respect them. But I actually could not respect them that they had actually considered doing that to somebody that was dying. And how would they feel if that was their relative or you know. Umm…. So I had sort of mixed feelings. I lost a bit of respect for them that I had had previously. In fact I had lost a lot of respect for them and it gave me, it made me realise that suddenly in the NHS a bed had become a bed and the patients were just missing in the middle of it’. Ross
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Ross felt confident, having assessed it as inappropriate to move patients into a
discharge lounge, that it was the right decision for the two patients to stay on the
ward in spite of it being in direct conflict with the instructions given by a senior
colleague. Ross felt uncomfortable that the situation had arisen and that there
appeared to him to be no alternative other than to refuse to comply with the
instructions. The fact that ‘a nurse’ would consider such action as acceptable
appeared to make this even more difficult to accept:
‘I cannot believe that somebody who is a trained nurse umm…. And actually I had done studying with I’d worked alongside could actually even contemplate moving somebody like that dragging them out of bed when they are actually fast asleep and terminally ill and I just could not believe it to be honest’. Ross
Ross indicated, through this account, the importance of values in nursing, the
expectation that nurses, for Ross, are expected to be particularly sensitive to the
needs of vulnerable people, that the National Health Service is not like other
organisations and that the person [patient] should be at the centre of decision
making (Benner, 1984; NMC, 2008; DH, 2012).
Nicky demonstrated how important patient safety was to her within her account and
was prepared to justify her decisions:
‘I’m running intensive care for that shift. I’m put in that position as leader of that shift to make decisions based on what I believe is correct, research based, clinical knowledge, patient safety......’. Nicky
Nicky also indicated that part of the problem was that the person who was
challenging her assessment of safety on the unit was a nurse, indicating that there
was an expectation that, as nurses, there ought to have been some shared values
and understanding of her assessment of the situation:
‘I was in that position and made that decision and it was taken out of my hands because 'it doesn't matter now, we're [matron and the site manager]
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overruling you. It doesn't matter that you're in that position, I don't care when you say it's unsafe'.....’. Nicky
When explaining, in the accounts shared during the interviews, how nursing
colleagues did not appear to share their values in relation to direct patient care, their
duty of care and professional accountability, Nicky and Ross were passionate; both
became animated, in both their verbal and nonverbal communication of the issue,
while expressing the level of feeling they had had.
Professional codes of standards / ethics and, in this case, The Code (NMC, 2008)
reflect the values of the professional group. Adopting these values forms part of
what Benner (1984) describes as socialisation into a profession where these values
become internalised by the members. Individuals become socialised into a set of
cultural moral values and beliefs through exposure to the group, as these values are
transmitted by members of the community and the behaviour of its members
(Settelmair and Nigam, 2007).
Here Charlie explained the conversation between himself and the Sister from
Radiology; the medical team wanted a scan performed but both nurses felt this was
inappropriate and were prepared to advocate to prevent the discomfort the patient
might experience. Undertaking the scan would not have changed the treatment plan
or outcome for the patient. Both nurses recognised the importance of advocating for
the patient, demonstrating their shared values in relation to facilitating a dignified
death for this man, as his prognosis had already been established:
‘know you're going to take this man down on Sunday morning for an expensive scan'. Our ward sister said look I’m not happy about taking this man, he's not well enough, I’m not bothered about taking a man who's poorly down and I worked in ICU I’ve only been here 6 weeks, I’m happy with that, but she said it's not
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going to change the outcome she said he needs care of the dying pathway, and I felt like we had to fight for this man, I felt we had to fight for him to die with dignity and we shouldn't have to do that’. Charlie This section of Charlie’s account provides evidence that, in this case, both Charlie
and the radiography Sister had a shared understanding of the patient’s situation and
opinion of what might be best for the patient.
6.2. Conclusion
Accountability and autonomous decision making were clearly expressed by the study
participants. Participants explained how, when faced with difficult ethical dilemmas
in practice, they were aware of their accountability. Brooke and Drew both discussed
accountability in relation to drug errors, clearly demonstrating both their
understanding of accountability and how it applies in a specific situation.
Other participants explained how they were able to make autonomous decisions for
which they were happy to be called to account; the level of accountability may be
influenced by the context of the decision or action, for example Sam had to manage
an underperforming member of staff and, although supported by managers, Sam
recognised the level of accountability held personally and professionally
Chris explained that it is part of the nurse’s role to advocate for patients and that any
decision made with or on behalf of patients must be justified, as nurses are
accountable for their actions, including when they advocate or fail to advocate for
patients; this is clearly identifiable in The Code (NMC, 2008)
Lee had a difficult time managing a dying patient’s discomfort and recognised that
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working outside Trust policy left him accountable with no security of vicarious liability
from the employing Trust. In this situation Lee was seen to collaborate with
colleagues, this is discussed further in Chapter 7.
Ross’s experiences when discharging patients also highlight how nurses feel that
advocating is an important part of their role and they feel distressed when other
nurses do not share their interpretation of the situation and the values that underpin
that decision. Nicky resisted moving a nurse in the team to another clinical area, as
a personal assessment of the situation identified that this would reduce the staff ratio
to an unsafe level, resulting in increased risk to patients on the unit. Nicky’s ability to
act autonomously was limited by the position held within the organisation and the
nurse was moved. It is evident that the participants were not always able to act
autonomously and they identified that their autonomy was limited by the position they
held within the organisations, Trust policy and the resources available at the time.
How participants have worked within these constraints, collaborating with other
nurses and the wider team, is further discussed in Chapter 7.
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Chapter 7- Collaboration and Conflict
7.0 Collaboration and Conflict
Collaboration or conflict, in some cases both, appears in most of the accounts
described by participants. Nurses do not work in isolation, within the context of
secondary care nurses work as part of a multidisciplinary team. How nurses engage
with other team members can be seen within these accounts. Within participant
accounts, working with various people, including the patient and their family and
other health care professionals, leads to situations of collaboration and conflict; the
objective, however, continues to be finding the best outcome for the patient. In some
accounts, such as Ross’s, there was clear conflict; other accounts demonstrated
how nurses collaborated with others to achieve what was viewed as the best
possible outcome. In Lee’s account this included almost colluding with others to work
outside Trust policy.
7.1. Collaboration
Charlie effectively summed up the importance of a shared vision and working
collaboratively when striving for the best outcome for the patient; here Charlie talked
about caring for a patient who was dying and using the care of the dying pathway, in
this case the Liverpool Care Pathway (DH, 2009):
‘I think we all sing from the same hymn sheet, and I think there are areas where what we do everybody does and yes I think it works. I think we know exactly where we're going. Once we've got that we know we're not giving non-essential medications, we're giving medications to be comfortable with, we're not filling them full of fluids which just you know hang around, we are just making them comfortable, and I think that's really important’. Charlie
For Charlie, collaboration occurred within the health care team when caring for a
patient who was close to death. Charlie’s account explained what each member
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contributes; the physicians are able to prescribe the appropriate medication to
manage the distressing symptoms which can occur when someone is close to death,
physiotherapists, when required, can help with breathing difficulties and the family
may know the patient’s values and wishes as well as the nurses. This approach to
end of life care is in line with Department of Health (DH, 2009) and National Health
Service standards of care (NHS, 2011) which, Charlie felt, have brought some
improvements to end of life care. However, both Charlie and Jo struggled with the
reluctance of some doctors to commence the palliative plan of care, resulting in a
delay in its implementation.
Chris’s account demonstrated how working collaboratively helped to promote the
patient’s welfare after discharge from hospital. Chris’s account moved beyond the
health care team to include social services, as the social worker is able to access the
resources required to achieve this. Chris explained that the need for social services
input had arisen from working closely with the patient and his family:
‘It's making that link. It's making the link of knowing who you can go to get that extra support and who's the best person to deal with a situation at the time and I think I liaised really well between him and his family and even Social Services and you're an advocate for patients aren't you? And it's important that you know that you're doing the right thing for everybody and it's bridging that gap and that support and not necessarily does he have capacity or doesn't he have capacity you know’.
Chris Like Chris, Ashley worked with other agencies to ensure the best possible outcome
for vulnerable individuals:
‘we do have a child protection nurse that's situated on the ward, she's here Monday to Friday, so if I have any issues I go straight to her and she'll tell me whether it needs dealing with or she'll take it on board.........we work with them in that we've probably still got the child, and they take over and sort of, once the child's gone home...’ Ashley
Chris and Ashley’s accounts demonstrated how nurses in secondary care pay
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attention to patient welfare whilst in hospital and on discharge home. By examining
Charlie’s account it is possible to see how the transfer of patients within the hospital
environment from one ward to another also requires nurses to work collaboratively to
ensure continuity of care and the best possible outcome for patients. This is in line
with their duty of care as health care professionals to their patients for both their acts
and omissions; working collaboratively to plan care to prevent foreseeable harm
(Caulfield, 2005; Dimond, 2008). In Charlie’s case, lack of continuity of care might
have resulted in an increased length of stay in hospital or emotional and
psychological distress for the patient. In Chris’s case, an unsafe discharge might
have resulted in harm to the patient who had been assessed as vulnerable. In the
secondary care context Charlie, like Chris, recognised the responsibility of the nurse
beyond direct care (Dimond, 2008; 2011).
When the non-availability of beds on the specialist ward resulted in the need to
transfer a patient to an alternative ward, it was Charlie’s responsibility to decide
which patient would be transferred and which would stay. Charlie worked
collaboratively with the nursing team on the receiving ward to try to minimise the
disruption to the patient’s care and try to make his experience of this change and his
stay in hospital as comfortable is it could be:
‘I related all the history obviously to the other ward, the problems with his son and his home circumstances, the problems we'd had with the pain team was ongoing, and I mean I said to the physios 'can you make sure you go sort of morning and afternoon just so he knows we haven't forgotten him, that he hasn't been sent off somewhere where that's it we're not having anything to do with you any more'. Charlie
Charlie ensured that the patient’s needs were effectively communicated, including
his progress and any plans made for discharge. Effective communication is
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essential between all members of the team, especially the patient and those
delivering direct care, if standards are to be maintained (Finkelman and Kenner,
2010):
‘we want it also to be a good experience, you don't want them to think about that experience and think oh it was absolutely dreadful and I never want to go there, we want it to be as good experience as we can, but also I want the staff to know him and know what he's capable of and what they're up against, because I think it's difficult if you get someone who's a complex discharge, you get them from no ward, you get half a handover and then you're sort of thinking well where are we here? How far have we got? Do I need to refer to Social Worker? Has he had a home visit? Has his wheelchair been balanced because he's a bilateral amputee? Charlie
Working collaboratively, following the loss of the specialist nurse from the team,
Jordan set about developing information and support for patients undergoing lower
limb amputation so that a good level of service was maintained:
‘Well, we're going to have meetings with the OT and Physio’. Jordan
Interprofessional working is viewed as the way to achieve the best possible patient
outcomes in complex situations (Johnson and Webber, 2010). Interprofessional
working has been on the United Kingdom government’s agenda since the late
1960s, however it gained momentum in the 1980s and by the mid 1990s was central
to the National Health Service reform (Torp and Thomas, 2007). The Nursing and
Midwifery Council now requires all new nursing programmes to include inter
professional learning so that newly qualified registered nurses have the skills to
effectively interact with and understand the roles of all the health care professionals
(Longley et al., 2007).
Working with other nurses within the immediate ward team is almost a subsection of
the above. For example, in addressing issues on the ward associated with the
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prevention of pressure ulcers, Brooke, as Charge Nurse, explained how a member of
the team was supported to develop a specialist role in order to ensure standards of
care were maintained effectively:
‘what I’ve done now is give her that day so she's supernumerary on the ward, so she hasn't particularly lost the office day but she's here doing it and she's doing all the tissue viability teaching on that day and she's doing the intentional rounding with them and she's looking at the paperwork we use and she has chances then to go to the link nurses meetings and any other meetings as well, and I make sure that there's a ward meeting on that particular day so she can do her teaching session as well, so we've actually turned it round and used it to quite a useful thing and it's also giving her a more fulfilled role so it's handing her scope of practice as well, because it's almost like once a month she's doing a specialist nurse role on the ward’.
Brooke
Brooke’s approach here was to maintain standards of care by encouraging the
nursing team to work together in their management of tissue viability, including the
prevention and management of pressure ulcers. Brooke demonstrated the
importance of this issue by charging one of the team to take a lead and ensuring
there was time for any plans to be implemented. Where there is cohesion within the
nursing team, which is likely to have a positive impact on the quality of patient care,
nurses are found to have greater job satisfaction (Adams and Bond, 2000). The
leadership style here was to lead with rather than lead over (Hood and Leddy, 2006);
although the nurse who took responsibility for leading this project was nominated, as
such, she did not hold a position of authority over others in the group. Nurses
working within secondary care fall into two main types of teams: (1) that of the health
care professionals other than nurses and the senior nurse and (2) direct care giving
staff, mostly nurses and health care assistants (Cott, 1998). The team referred to
within Brooke’s account would fall within the second type of team made up of direct
care giving nurses.
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7.1a Collaboration with Patients and Families
Patients’ wishes appear to be at the centre of the way nurses work and this informs
their decision making. Participants recognised the contribution patients’ families
make in promoting this as they often have a greater knowledge and understanding of
what the patients want in cases where the patients may not be able to fully engage
with decision making themselves.
Ashley explained the importance of trust in the relationships nurses share with their
patients. This can be problematic for children’s nurses as children are not viewed as
having capacity to make their own decisions:
‘because we've got the trust of that child, she's trusted us with that information, she doesn't even want us to tell her mum so if we're going to go and tell the authorities.... do you see what I mean?..........Depending on how much time you've got you might talk to the child.............. Ashley
Ashley explained that it is the time nurses spend with patients, especially with
children, that helps to develop good relationships. This helps them understand the
patients’ wishes and work in collaboration with them and others to achieve the best
possible outcome and to avoid conflict. It is the close relationship that nurses have
with patients that facilitates a unique perspective that contributes to and influences
the decision making associated with patient care (Storch et al., 2004; Lamb et al.,
2011).
‘the girls [nurses] can get, you know, quite …. especially on nights, if you've got a teenager you might sit and talk to her for hours’. Ashley
Jo also identified the importance of developing appropriate relationships with
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patients, recognising that this takes time but is necessary to ensure that a proper
understanding of the patients’ wishes is gained:
‘...... we have patients for anything from 3 days to 4 months because sometimes they've social side and we get to know the patient and the family, as daft as it sounds, is sort of like our family and the patients are like our family because you get to know them really well and you get really, really close with them’. Jo
Chris and Jordan explained the importance of working with patients’ families. Chris
understood how important this was when resolving issues of patients’ vulnerability on
discharge from hospital. Chris was able to work with the patient’s daughters in
finding a solution to his problem and helped them support the patient with the
changes he was facing in life:
‘‘..................obviously getting his family involved helped a lot....he was, he's
really close to his daughters and in fact he was really happy with the outcome as well which made it even better’. Chris
When developing information and a support plan for patients following lower limb
amputation Jordan not only involved other health care professionals but recognised
how patients’ families could also make a valuable contribution:
‘Yes, we're going to get the families involved as well because obviously they need support as well’. Jordan
It is important that nurses work closely with patients and their families to ensure high
quality care and to support patients to stay healthy (DH, 2008, NMC, 2008).
7.1b Collaboration with Doctors
Doctors are also health care professionals and have a long history of working with
nurses. The changes that have occurred in the nurse’s role and positions held by
nurses within the NHS have impacted on the way these two professional groups
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build effective relationships (Davies, 2003). The way these two professions work
together has the potential to have a significant impact on patient outcomes (Faulkner
and Laschinger, 2008). Whilst this section focuses on the collaborative nature of
relationships with doctors, it also illustrates how close the relationship between
collaboration and conflict can become.
Jo explained that being able to engage assertively with doctors is something that has
developed with experience and through the building of effective professional
relationships with the medical team:
‘I think that's come with getting to know the doctors, more so working over at xxxxxx because you have more time to talk to them there. I got to know the consultants a bit more and you get to know the doctors because they're all on the ward for about 6 months at a time, you get to know them slowly and I think you just get more confident and the more you're qualified and the more experience you get, the more confident you are’. Jo
Jo explained that this can, however, depend on the individual doctor:
‘Some of them, there's the odd one or two that think you know 'I’m consultant, I’m the doctor and you're wrong', but usually they're pretty good and they listen to what you think and they'll take on board what you think’. Jo Jo recognised how when nurses and doctors work together in this way, there is the
potential to improve patient care (Faulkner and Laschinger, 2008).
Nicky expected support from the doctors who formed part of the team in the
intensive care unit. However, on this occasion the response was less than expected.
Nicky was concerned about maintaining safety on the unit and the risk to the patients
if staff were moved away. The doctor’s opinion was that because it related to
nursing staff, it was not an issue in which he wanted to become involved. This was a
disappointment for Nicky:
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‘I felt the other side of the coin was, I spoke to the consultant who was on for the weekend and he wasn't interested. He basically said 'well it's a nursing issue' and I said 'but it's not though is it? Because at the end of the day you're in charge of this unit for a doctor and medical point of view and we haven't got any.... I’m telling you that there's patients who are going to be left unattended and clinically if something goes wrong....' and he just said 'well it's a nursing point of view, what do you want me to do?'. I said 'well, I’d like you to back me up and say actually no you're not taking a nurse' and he wouldn't’. Nicky
The differences in the roles which can have an impact on the way these two health
professionals collaborate were further exacerbated by the organisation’s hierarchical
structure (Oberle and Hughes, 2001).
Ashley tried hard to help the parents of a child needing life saving surgery to
understand why it was essential and to assure them that blood products would not
be administered in theatre:
‘In the end we had to get a consultant paediatrician and an ENT [ear nose and throat] Consultant to come in, in the night to speak to these parents, because they still wouldn't budge’. Ashley
Unfortunately, on this occasion the doctor’s attempts were unsuccessful and the
case was taken to the court of protection. Under the Mental Capacity Act (2005)
adults and children who have limited capacity to make autonomous decisions are
provided for. Where there is a serious conflict of opinions the court of protection may
be accessed in order to make the decision and ensure that the patients are
appropriately represented (Dimond, 2008).
Ashley’s account explained how the team struggled with a family’s decision not to
allow a child to undergo surgery, based on the fear that blood products would be
given against their wishes and beliefs. At this time the child required surgery to
avoid death. The surgeon did not think there would be a need for blood products
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and, though the parents had been assured none would be administered, they did not
believe this and refused to consent to the surgery.
Ashley explained how the beliefs of the child’s parents were so strong that even
when their own minister tried to assure them that surgery was the best option for the
child, they were not happy:
‘I don't know what they call them, for want of a better word – the priest of the Jehovahs Witnesses, they've probably got another name, but whatever they are, they got him in and he actually tried to persuade these parents and I can't remember how it all came about, but in the end they had to.... they took out some kind of legal ….......’ Ashley
Having engaged members of the health care team and the family’s minister to try
and find a resolution which they were happy with whilst trying to save the child’s life,
Ashley explained that the only option was to go to the court of protection:
‘That's right and they overturned the parents and the child went to theatre and was intubated and everything was fine’ Ashley
Ashley felt sad that the parents did not understand. It was not that the health care
team were trying to override the family’s belief system. The intention was not to give
blood. The family did not trust the health care team and continued to refuse to
consent to the surgery.
Lee’s collaboration with doctors to minimise the harm, in the form of distress and
discomfort, resulted in both of these health professionals knowingly working outside
Trust policy:
‘as a registered nurse, you know absolutely damn fine that you should never take a drug prescription over the telephone. The alternative was to parcel the patient into an ambulance along with the prescription chart have the shipped across ‘Town’ so a Doctor could write on a prescription chart and look at the patient. And write them up for some drugs and ship them all the way back, but quite often we were
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dealing with people who were frail who were older. For people who were elderly it would be really disruptive, dense strokes you know an awful lot of trauma to your patient to do that’. Lee
Lee, in order to avoid the patient having to be moved to the main site for drugs
prescribing, as described above, worked with the doctor who prescribed the drugs
verbally over the telephone to two nurses in order for the drug to be administered.
Lee’s experience indicates that this was the usual custom and practice especially
where patients are cared for on peripheral sites, without a duty doctor; it is the ward
doctor who will sign the prescription the following morning:
‘I even used to think about doctors doing it I mean doctors feel or appear to be quite blasé about it they were quite happy to do it. I used to think how do they feel prescribing a drug for a patient they have never clapped eyes on, how do they know – they are very trusting themselves’. Lee These two professionals worked together to achieve what they believed to be best
for the patient although they both knew it conflicted with their employing Trust’s
policy.
7.2 Conflict
Whilst it is possible to identify collaborations, many of these accounts also
recognised that developing relationships to aid ethical decision making can lead to
conflict with other members of the team, patients and their families.
Doctors and nurses are seen to come into conflict about patient care, including
treatment which has traditionally been viewed as the doctor’s domain (Oberle and
Hughes, 2001). However, nurses are required, through their code of conduct, to
challenge doctors’ orders where they are perceived to not be the best possible
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option (NMC, 2008). Nurses are accountable, as discussed in Chapter 6, for their
actions regardless of directions given by others (NMC, 2008).
7.2a Conflict with Doctors
Both Charlie and Jo explained how they experienced conflict with the medical team
when caring for terminally ill patients. The conflict occurred when they were
struggling to influence the doctor’s decision regarding the patient’s plan of treatment
and care. Charlie used strong language to demonstrate the depth of feeling aroused
by the decisions that had resulted in the conflict between the plan of care prescribed
by the doctor and what Charlie believed to be best for the patient:
feel that you know we should have dignity in death and I don't always think we do and I don't think that's a nursing fault, I think it's a doctors fault, I think our surgeons think if they can save life if someone has a pulse then they're alive and there's no quality’. Charlie
Jo had similar issues in relation to the care of the dying and explained how attempts
to work with doctors and influence changes to the plan of care were not always
successful, resulting in conflict. Jo explained why, as the nurse caring for this
particular patient, it was felt that commencing the patient on the care of the dying
pathway earlier would have been better than the decision taken by the doctor to
keep trying curative treatment for longer:
‘Yes, and I just think she just needed to be comfortable and you know spend her time with her family. We had to keep pulling the family out of the room to do all these tests and you know they needed to spend the last couple of hours with their mum. I just thought....you know it was unfair, on the relatives and on the patient’. Jo
Historically nurses’ roles were viewed in terms of supporting the work of doctors and
following doctors’ orders (Pugh, 1944). Substantial changes have occurred over the
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decades. Nurses are now required to challenge doctors’ orders (NMC, 2008) where
appropriate; they are accountable for their actions and following the instructions of
others does not relieve them of their accountability (NMC, 2008).
7.2b. Conflict with Patient and Family
Conflict can occur, however, when patients’ or their families’ expectations are not
realistic:
‘because sometimes you get families that you know might not be that bothered and they're just like 'well we want this', sometimes if you say it's a DNAR for instance, the family says 'well I don't want a DNAR', unfortunately it's up to the doctor, the family can't decide. Now they'll discuss it with them but if they think it's in the patient's best interest then they'll do it even if the family kick up a fuss and say 'we don't want it, or we do want it', the doctors have overall.... you know they can decide overall, not the family’. Jo
There are a number of reasons why this occurs. Firstly, in some cases the treatment
would be futile and therefore be an unjustifiable use of resources (Beauchamp and
Childress, 2001). Secondly it is important to consider the patient who may be
receiving futile treatment, as this has the potential to cause harm through stress and
may give the patient or family false hope and unrealistic expectations (Hurst et al.,
2005; Clará et al., 2006; Gallagher, 2010).
Jo explained how, when treatment options are at the health care team’s disposal,
they may not be made available, for example, attempts to resuscitate:
‘they [doctors] do discuss it with patients if you know they understand, and to be honest with you the patients usually do understand and they're quite happy for that and a lot of patients actually say 'if anything happens I don't want any resuscitation'. Jo
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Ashely explained in depth how complex and distressing decision making can
become when there is conflict between the health care team, of which the nurse is a
member, and the family of a child in their care:
‘.......she was only 3 or 4 I think and she had tonsillitis, and during the night she got worse and worse and when we looked her tonsils were practically meeting in the middle, to the extent that she needed to go to theatre to be intubated, which you would think would be fairly straight forward except her parents were Jehovahs Witnesses, and they wouldn't let her go to theatre in case we gave her a blood transfusion. We explained that there was no way she was going to have a blood transfusion but they still wouldn't, and we spent a lot of time trying to persuade these parents, and they wouldn't be moved,..........but at this point we're responsible for the child... ‘ Ashley
Finally, things went to the court of protection:
‘......they overturned the parents and the child went to theatre and was intubated and everything was fine, but apparently they had an older child who had been to theatre and had a blood transfusion, and that was why they felt so strongly about it, but I mean the doctors were prepared to swear in a court that they weren't going to give this child a transfusion’. Ashley Throughout this Ashley was still able to empathise with the parents’ anxiety and
respect that this was their belief, recognising the conflict:
'We explained that there was no way she was going to have a blood transfusion, which you know is fine, it's their belief ..........as a mother I can't agree, as a nurse I can't agree and as a catholic I can't agree', Ashley Ashley’s account was filled with understanding for the family but concern for the child
in the situation and real concern for the child’s life. She demonstrated how strongly
she felt, drawing together roles as ‘mother’ ‘nurse’ and ‘catholic’, thus illustrating the
way in which her decision making was influenced in different ways. The family’s
beliefs were recognised but these were in conflict with Ashley’s and those of the
team and what was felt by the team should be done in the best interests of the child.
This included their duty of care to the child as the first concern and respecting that
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child as an individual with rights separate to those of the parents, although she had
not reached the age at which capacity to consent is formally recognised.
The Mental Capacity Act (2005) has laid down guidance and regulations for those
adults without capacity to make a decision in a particular situation, however, for
children it is more complex and may involve several agencies. Decision making
where there is conflict regarding the treatment of a child can involve a wide number
of agencies as well as the child, the family and the health care team. Decisions
should be made collectively and Gillick competence and Fazor’s Law (Payne, 2008)
are used to help determine the ‘right’ action. In the situation above things went to the
court of protection for a final decision as the situation could not be resolved any other
way.
7.2c Conflict with Nurse Managers
For the participants interviewed within this study it was this conflict that appeared to
have the biggest impact on both the care delivered and the nurse participants, as
they appeared to believe that, as nurses, these managers should have a shared
understanding of the dilemma and should share the values that informed the
participants’ decisions.
Drew explained how a direct instruction from an immediate line manager was felt to
be inappropriate and therefore Drew did not undertake the task as instructed:
‘I was asked would I give a drug to a patient by my line manager and I didn’t feel that the patient should have the drug’. Drew
This was not an easy thing for Drew:
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‘But I felt a bit threatened by my manager because he kept advising me that I should give this drug to calm the patient down so that the patient didn’t climb out of bed because the patient was confused umm… and the patient had cot sides up.... Drew .......So at the time I felt under pressure because this person was my boss and I was a very junior staff nurse Ummm…. And he was ordering me to give this drug in front of other people such as some of the medics that happened to be around the ward at the time and umm…’ Drew Following instruction from a nurse manager Ross explained the feelings caused by
refusing to follow instructions:
‘although because at one time we were equals she was now actually yes she was bed manager but she was a higher grade than me as well so umm… in a way it gave me numerous feelings because one my values and beliefs are that this is somebody that is on a higher grade than me and you should respect them. But I actually could not respect’. Ross Nurses’ roles may vary according to their position within the organisation, however,
all have responsibilities to ensure that high standards of care are maintained (NMC,
2008). The context within which nurses work can have a limiting impact on the care
delivered as resources may be limited (Oberle and Hughes, 2001; Colebatch, 2009).
A common example identified in the literature, within the context of limited resources,
is the pressure on bed occupancy within NHS Trusts (Oberle and Hughes, 2001;
Sinuff et al., 2004). This is supported by the National Audit Office (NAO) who have
reported that emergency department hospital attendances have risen 47% over the
last 15 years with more of those attending requiring hospital admission (NAO, 2013).
This can lead to conflict manifesting in a resultant ethical dilemma. In Chapter 6
Ross demonstrated her autonomy in a decision not to move two patients from the
ward and remained steadfast in refusing to follow the instructions of the bed
manager. Despite being pleased to have made the right decision, this did cause
conflict:
‘I did not care who thought I was wrong at my decision that I made and I did not move either of those two patients. And seriously did not care they could have sent the chief executive on the ward I would have stuck to my guns and did what I thought was best for those patients’. Ross
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‘Eventually when she rang me again, the bed manager, umm…. I actually told her exactly what I thought umm…. And she just said ‘Ok ok, I’m not moving them, but she never came and apologised for the fact that she even contemplated moving them. And I did not hear anything back from anybody’. Ross
Unfortunately for Ross, although the decision made to keep the patients until they
were taken home was followed through by her actions, there remained
disappointment in the conflict experienced.
Lee’s account was less about an individual person but explained how policy which is
associated with nursing management as has resulted in the problem. Lee explained
that Trust policy may at times be at odds with what the nurse views as a professional
obligation, resulting in conflict:
‘because of what you have to work with because of the rules and regulations and the policies and everything else so you do feel to be in an ethical dilemma really because you think your professional body and people are saying one thing but in reality your practice are saying you should do another one. Which sounds a bit confused..............................I think it is an ethical dilemma if it wasn’t maybe it was just a policy issue but ethically I felt pulled I felt I should have been .. and I did not I should have been ringing somebody and starting it out but my gut instinct was to say no because it was going to cause that much fuss and problem because you have worked with the system before’. Lee
Nicky had the same experience when challenging the decision to move a nurse from
the intensive care unit. Nicky showed a strong sense of respect for nurse managers
and was concerned that by trying to do what was felt to be best for patients in the
unit, she was perceived to be obstructive:
‘I really felt berated, I really felt like I was just being militant and I was being obstructive and I wasn't, so it was very difficult’. Nicky
Lee recognised that there are a number of things that may impact on what nurses
are able to do for patients. These include, in some cases, patients’ families, other
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health care professionals, Trust policy and the available resources, whilst nurses still
strive to do the best for patients:
‘quite often we were dealing with people who were frail who were older. For people who were elderly it would be really disruptive, dense strokes you know an awful lot of trauma to your patient to do that. And err for years and years and years we asked our management to sort something better out’. Lee
7.3 Conclusion
Both conflict and collaboration occur when addressing ethical dilemmas in the
context of secondary care. In a sense these are two ends of a single continuum;
once agreement about a plan of care has been made, collaboration can occur to
ensure that this is delivered effectively but conflict can arise when all parties do not
agree.
The importance of team and interprofessional decision making to achieve best
patient outcomes can be seen throughout participants’ accounts and the importance
of communicating effectively with everyone involved. Collaborative interprofessional
working is essential to ensure high standards of care are delivered where possible,
developing shared goals (Botes, 2000a).
Both collaboration and conflict between doctors and nurses in participants’ accounts
tended to relate to direct patient care, in particular in relation to the care of the dying
pathway and when to commence this for patients who appear to be terminally ill.
This may be explained by the differences in the perspective of care for nurses and
doctors, with doctors’ emphasis on treatment and cure (Torjuul and Sørlie, 2006).
However, the organisation’s hierarchical structure may have a greater impact than
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the different perspectives doctors and nurses bring to these ethical dilemmas
(Oberle and Hughes, 2001).
Collaboration between other health care professionals was also identified as being
important if patients were going to receive the best outcomes, both during their
hospital stay and after discharge; in some cases specialist services were also
involved (DH, 2000).
Collaboration with patients was identified as an essential part of getting the right plan
of care in place; the building of effective relationships with patients and their families
was viewed as an essential part of achieving this (NMC, 2008).
In extreme circumstances where following policy was viewed to be potentially
harmful to the patient, Lee identified how nurses may risk ‘bending the rules’ to
achieve what is seen to be the best for the patient, even when this involves colluding
with other health care professionals.
Conflict has been identified within participant transcripts where team members, for a
variety of reasons, held different views of what might be the best option. This, in
some cases, was differences based on the values and beliefs of team members,
including various health care professionals, patients and their families. Conflict may
also occur where the first choice of action is obstructed by Trust policy or limited
resources. For both Nicky and Ross this caused their distress and disappointment in
colleagues who failed to support their preferred course of action. Concern for others,
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including colleagues as well as patients and their families, is a feature of the conflict
experienced and is the focus of the next chapter
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Chapter 8 - Concern for Others
8.0 Concern for Others
Although the dominant theme throughout all the accounts was about striving to do
what is best for the patient, including the delivery of high quality care, a smaller but
significant theme was that participants also demonstrated concern for others. The
concerns expressed were about the other people involved in the dilemma and the
impact that any decisions made would have upon them. The following examples
demonstrate how far-reaching these concerns were; they went beyond the patient’s
immediate family to other patients who also use health care facilities and resources
and other members of the health care team. Where concerns had been raised that
impacted on the health care team, participants’ accounts indicated the desire to do
the best they could to ensure that team members felt valued and that their best
interests were also considered to be important.
Brooke explained how, when the management of pressure ulcer preventions on the
ward was under scrutiny, efforts were made to make staff feel valued and maintain
staff morale and she saw this as an opportunity for all the staff to improve their
knowledge of tissue viability, pressure ulcer prevention, management and the latest
guidance from the European Pressure Ulcer Advisory Panel (EPUA), and National
Pressure Ulcer Advisory Panel (NPUA) (EPAU and NPUA, 2009; EPAU and NPUA,
2010). Brooke explained the situation and her concerns around staff morale as, at
this time, they might have felt under scrutiny. Brooke appointed a nurse to take on
the role of tissue viability link nurse and ensured that the nurse was given time
during the working week to develop practice on the ward. Brooke was extremely
concerned about the morale of all the team members and expressed that it was
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important to consider this and to take measures to ensure they did not feel
reprimanded but understood that good practice did exist and that the incident would
provide further development opportunities:
‘as a manager you've got to then find ways of putting mechanisms in place to stop that happening again, but also to make the staff feel supported and because they are very passionate about nursing and I do believe people do this job because they want to care on the whole, they take it all to heart and it's all against them and you feel staff morale go down as well’ Brooke.
Brooke attempted, through effective leadership, to empower the ward nurses to
improve care and to ensure that they felt valued. A variety of leadership styles can
be effectively used within health care settings; styles which focus on relationships
within the team are seen to produce better outcomes for the nursing workforce
(Cummings et al., 2010). These relationships involve the patients themselves as
well as other members of the team and the investment that nurse managers put into
the relationships they have with their nurses will have a positive impact on the well-
being of the nursing workforce and, consequently, outcomes for patients (Cummings
et al., 2010):
‘I’ve also talked to all the staff as well and I’ve said 'actually you're very highly thought of', and in fact two of the managers have been on the ward and have been really, really supportive of me as well now, because they realise how sort of passionate we are about it and how we just don't want this to happen, but how just sometimes things like that are unavoidable, somebody will fall [for example], you know you can't stop it all the time’. Brooke
Brooke explained why effective working relationships throughout the team are so
important and how a culture of care can impact on the way people feel:
‘I am passionate about my job, my work and my staff and I want to look after them, and I see my role as not only a manager but also pastoral really, I’m looking after their needs as well, and that makes a stronger team and it shows that I care about them, you know within the realms of confidentiality they all come and tell me things that never goes anywhere else except you know in here between them, but also I feel that's the best way of leading people, isn't it? You know leading from the
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front and showing that you actually care. I mean they could tell I was actually upset last Monday and I thought that was really touching, and a few came and gave me a hug and I thought 'oh God, that's really lovely'. Brooke Brooke showed how important the nursing team are and how, as Charge Nurse, she
was concerned about the impact this was having on them and strove to make them
feel cared about. This is important as Brooke wanted to maintain staff morale,
treating team members with sensitivity to reduce any stress or loss of self esteem
amongst staff members. Issues identified in the literature that impact on morale and
job satisfaction amongst nurses include increased stress associated with limited
resources and time constraints which negatively impacts on work place relationships
(Hong et al., 2011). Similar concerns were expressed by Nicky following the
request to move staff from the unit, which has been explored in Chapter 6. This had
resulted from a shortage of staff which, in turn, had impacted on the relationships
with both the doctor who was approached for support and the senior nurse who
made the decision to move the nurse from the unit.
Sam’s account of trying to resolve issues with a member of the nursing team whose
behaviour on the ward fell below the required professional standard also revealed
how he was concerned not only for this particular staff member but also for the other
staff on whom this situation impacted. Concerns had also been raised about this staff
member’s competency in relation to caring for the particular types of patient on the
ward, having only just joined the ward team. The nurse in question had required
redeployment due to changes in service provision within The Trust. As time
progressed, regardless of Sam’s attempts to support this nurse, standards of care on
the ward were being negatively affected as the situation impacted on other staff
members, particularly unregistered health care assistants. Sam was using a
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relationship focused approach to leadership (Cummings et al., 2010) to try and
improve nursing outcomes and patient care.
Recognising the importance of addressing these issues, Sam continued to work with
this nurse in an effort to bring her practice up to the required standards and to
support the ward team. These efforts resulted in Sam having a little time away from
the ward and working with senior nurses to try and ensure appropriate professional
development was achieved. Like Brooke, Sam (also a Charge Nurses) demonstrated
a high level of commitment to the ward staff as well as to patients.
Whilst addressing problems and complaints associated with this, Sam continued to
invest time and effort in this nurse, trying to facilitate her professional development
until there was no option but to take formal procedures:
‘I wanted her to succeed but the staff who had issues with her, they said she'd never [change].....................but I never give up on anybody me, I've always been that kind of person..... Because it's nature to... I've always put a lot of effort into people that are difficult or are struggling..... I think in my heart of hearts I knew how bad it was going to go in the end, I knew eventually something would happen because as every month went by, whenever there was an issue, a dilemma, a complaint, or something it was always worse, it got that bit worse every time.’ Sam
Sam showed the fundamental value placed upon people. Although Sam recognised
that this was a situation where things could not be changed, he continued to try:
‘I put my heart and soul into guiding her along really put a lot of effort into working through, checking with her, trying to support her, and feeling a bit sorry for her really at one point because she was under a lot of pressure’. Sam
Following a serious incident Sam recognised this had to be formalised and referred
to senior management and the human resources department; he recognised the
impact this might have:
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‘I had to escalate it straight away, and I sat in the office for 20 minutes thinking what do I do here, what do I do here? I knew the consequences once that call was made and that document was filled in............ The seriousness of the incident and what I believed to be the lack of numerous things that led to it that were not done for whatever reason. Sam
Sam clearly struggled with making this decision because of the consequences that
would follow for the nurse. However, in addition to patient care, Sam was also
concerned for herself and other staff on the ward:
‘I was worried about my registration and I was worried for my staff because
she would just pass the blame for things onto other people’. Sam
An unexpected outcome for Sam was that when this member of staff no longer
worked on the ward, the team pulled together to ensure good quality care was
delivered; this might have been a result of Sam’s approach to leadership combined
with the team’s shared goals, which had not fundamentally changed.
It is evident from Sam’s account that, whilst going through the process of providing
support, setting targets and identifying areas for improvement with regular review
meetings, Sam was concerned not only for that particular nurse. The impact it was
having on quality of care on the ward and the impact it was having on the remaining
team members were of equal importance. Dilemmas of this kind go beyond direct
patient care and those in management positions face different dilemmas to nurses
responsible only for direct patient care. Similarity in the approaches taken by nurses
can, however, be recognised.
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Sam demonstrated that the value placed on the individual is not person specific, she
valued and was concerned about all the staff in the team and the patients in their
care.
As discussed in Chapter 7, another participant, Lee, had collaborated with the
doctors to access the medication required for a particularly frail male patient. Not
only did Lee express concerns for the patient but also for his family and the
prescribing doctor who ‘bent ‘ the rules to achieve what was considered the best
action for the patient.
Lee, the other nurse checking the medication and the prescribing doctor all put
themselves at risk. Lee justified the decision to take a verbal drug order over the
telephone as this was perceived to be what was best for the patient and, by following
Trust policy, the patient would have been at risk of experiencing avoidable upheaval
and further distress. Lee also demonstrated concern for all those who were involved
in the dilemma, not only the patient, his family and other health professionals, which
echoes the values demonstrated by Sam:
‘We have got to start upheaving her we have got to get a stretcher we have
got to move her out and upsetting basically the whole family and the whole system’.
Lee
Charlie’s dilemma was deciding which of the equally dependent patients on the ward
would be moved to provide a bed for an ‘outlier’, Charlie weighed up the impact on
each patient and, whilst there was an acknowledgement that transferring the patient
identified to move was not ideal, Charlie was also concerned about the patients
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waiting to be admitted to the ward. This dilemma forms a detailed case study in
Chapter 9, so is not discussed further here.
When managing patient care in the final days and hours of life, the accounts
provided by both Jo and Charlie not only considered the impact the patient’s care
has on the patient but also the effect on their family, who experience their own
suffering during this time. Charlie explained how delays in implementing the end of
life care pathway (DH, 2009, NHS, 2011) had impacted on the family as well as the
patient. Charlie and Jo both recognised this in their individual accounts (see page xx)
8.1 Conclusion
It has become evident that the concern that nurses have for others is far reaching
and that, whilst the patient’s care and what is perceived to be best for the patient is
at the forefront of the decisions, nurses do consider others, recognising the impact
on those both directly and indirectly affected by the decisions and actions
undertaken by them as part of their professional roles.
As in other themes examined, [best for the patient, autonomy, collaboration and
conflict], professional relationships have an impact on what nurses are able to
achieve for the patient and others involved. When concerned for staff morale, both
Sam and Charlie used a relationship based approach to resolving the dilemma,
striving to help make improving standards of care a positive experience for the
nursing team (Cummings et al., 2010).
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When managing the care of dying patients, nurses develop close supportive
relationships with patients and their families, which results in the ability to advocate
for the patient and their family when negotiating care with the health care team
(Peter et al., 2004; Storch et al., 2004). The concern for their families is upheld in the
accounts of both Jo and Charlie.
In summary, in this section on ‘concern for others’, these extracts serve to
demonstrate a strongly held belief that people are important and that their welfare is
the concern of nurses. This reflects Kant’s proposal that humans have an intrinsic
value, that each has the right to self direction and the associated principle of
autonomy (Cahn and Markie, 2006).
Having completed the presentation of the thematic analysis of participant accounts in
Chapters 5-8, Chapter 9 will present a single critical account in context and highlight
where these themes appear and where and how the relationships developed by the
participant influence ethical decision-making and the participant’s ability to achieve
moral action. Within Chapters 9 and 10 the theoretical framework will be critically
discussed and debated within the context of these findings.
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Chapter 9 – Case study
9.0 Case study
In this chapter a single case study, drawn from one ethical dilemma presented by
Charlie, has been selected to facilitate theoretical analysis. Both content analysis
and interactional analysis have been undertaken, looking at the dilemma and the
reasoning, decision making and contextual influences within it.
Charlie, who is a staff nurse with in excess of thirty years experience, explained how,
on a regular basis, nurses are required to make difficult decisions about which
patients may be moved to another ward area to ‘out lie’. This is when a patient is
cared for on a ward that does not necessary routinely care for patients with a
particular condition and where the team of doctors managing the medical or surgical
aspects of the patient’s treatment are not routinely available but do routinely visit.
Thus, the house officer and registrar who spend time on the ward where the patient
has been sent will not be familiar with the patient’s situation; those who are may
need to be reminded to visit to review the patient.
Analysis of this case study has facilitated a deeper understanding of the relationship
between the themes from the research and how they work together in context. The
re-conceptualised theoretical framework can be found in Figure 2, where the stages
of the framework are redrawn and the element of ‘relationships’ added as an
overarching element.
Using a diagrammatic format, each stage of the theoretical framework has been
linked to Charlie’s account. Analysing Charlie’s account in this way has helped to
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clarify the beliefs and values that underpinned the decision to move this particular
patient to ‘out lie’ in another ward. This approach has also revealed more clearly how
and when the relationships the nurses developed were crucial. The analysis leads
me to believe that nurses’ ability to undertake moral action, in order to do what is
perceived to be the best possible outcome for the patient, is significantly facilitated
through the skilful development of professional relationships
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9.1 Reconceptualised Theoretical Framework.
Figure 2: Reconceptualised Theoretical Framework
Moral Action
underpinned by virtue
Ethical Decision Making Agent centred Virtues: compassionate, open minded, courageous Ethic of care: relationships with others: patients, their families, the health and social care team
Act centred Deontology : Respect for persons / autonomy Equity treating patients fairly according to need Minimising harm striving for the best possible outcomes Reasoning and justifying their decisions Consequentialism / utilitarianism careful use of scarce resources
Moral Reasoning
Values The patient
Other people Truth telling
Professional relationships
Beliefs Patients come first
Nurses have a shared value system Others are important
Team working is essential Restrictions exist
Ethical Dilemma
In Context
Equally unacceptable options
Secondary care context :
Limited resources
Increased technical and expensive intervention
Blurring of professional boundaries / New nursing roles
R
E
L
A
T
I
O
N
S
H
I
P
S
Nurse patient
relationship
With other patients, patient families, members of the
health and social care team
In partnership
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Charlie’s Dilemma Relationships Theoretical Framework Ethical Dilemma:
CHARLIE: Well I think the one that
immediately springs to mind is when
we're asked to actually move the
patient off the ward, because the
patients have had some major xxxx
surgery to come to us and you look
round and all our patients are unwell
and who do you move? I mean I look
and I think – do I move the amputee
who really needs the attentions of the
‘specialist’ physio every day? Do I
move him? Do I move the gentleman
that's only had a debridement of his
foot, but if he goes to another ward it
doesn't get the dressing done? Is he
potentially going to go for another
debridement? Do we move the elderly
lady who's had some surgery but she's
a bit confused and then you're moving
her somewhere else and she becomes
even more confused? And I think I
find that probably the hardest, I
struggle with that – who is the best to
Discussing a recent incident
where Charlie was required
to identify a patient for
moving to other ward areas
to make room of a newly
admitted patient. Charlie
has a comprehensive
understanding of the
patients and begins to
consider in detail the impact
on the patients.
Demonstrating how strongly
Charlie values the patients
and how important the
patient experience and care
is to Charlie, Charlie
explains that all the people
in her care are unwell,
leaving Charlie with an
ethical dilemma, presenting
two or more available
alternatives which appear
equally undesirable (Hamric
Nurse:
patient
relationship
Nurse: other
patients
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actually move? et al., 2000; Beauchamp
and Childress, 2001;
Noureddine, 2001).
Charlie’s Dilemma Relationships Moral Reasoning:
CHARLIE: I’ve really got to go through
each patient individually and sort of
think who's best placed to go? Who's
likely to do well? I mean sometimes it
tends to be actually the amputees that
get moved, mainly because they've no
wounds or anything and quite often
some of them can wheel themselves
down to the physio department, so it
tends to be them.
But sometimes it's really.... if you've
got someone.... because we are
xxxxxx the type of patient we have,
sometimes their wounds don't do very
good so you can really struggle with
15 patients as to who's best placed to
actually move, because we do have
patients that are with us for months at
a time, we've just recently had a
gentleman died and another lady was
Charlie begins to identify the
options and the unknown,
unable to predict the future
needs of each patient and
what the impact of the move
might be on each of those
who Charlie may choose to
move. This indicates that
Charlie has already found
that the consequentialist
approaches to ethical
decision making have
limitations but may need to
be utilised.
Charlie wants what is best
for each one of the patients,
and knows that to be moved
to an outlying ward is not
the best for any these
patients. This theme is the
Nurse: other
patients
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discharged to a nursing home, one
had been with us for 6 months and the
other was 7 months and the hospital
does do an audit for patients that have
been in for over 10 days, and for quite
a long period of time we only had one
patient who had actually been with us
less than 10 days and we did that over
a month period so it's difficult and
there's so many of them, it's really,
really difficult to.... I think actually we
did have a gentleman fairly recently
that was a bilateral amputee. He'd
had an amputation perhaps about 18
months ago and he came in and had
the other leg off.
dominant theme from the
thematic analysis of the
accounts provided by the
nurse participants; it is this
value that nurses hold
regarding patients that
influences their moral
reasoning and makes
moving patients an ethical
dilemma for Charlie.
Charlie also knows that
there is a patient waiting to
be admitted who requires
specialist care and what is
best for this patient is to be
admitted to Charlie’s ward.
From an early stage in the
account provided Charlie
begins to articulate the
importance of the nurse
patient relationship,
reflecting how the nurses
value the patient as an
individual and the
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responsibility felt towards
the patients and their
experience, as seen in the
thematic analysis and
indicated in The Code NMC
(2008). When considering
the complexity of the
problem Charlie
demonstrates how the
situation requires multiple
relationships with numerous
patients simultaneously to
be maintained. Balancing
the interests of individual
patients within the group
can result in difficult
situations for the nurse.
Charlie’s Dilemma Relationships Ethical Decision Making:
CHARLIE:
We were struggling with him actually
on the ward and it was really quite
difficult to get him moving. This
gentleman has quite a complex past
medical history and had an awful lot of
pain and his ongoing pain was very
The value placed on the
individual and their
experience informs Charlie’s
initial responses to the
situation, demonstrating the
value Charlie places on the
159
difficult to manage and sad to say he
was actually the best patient to
actually move, and it was so
inappropriate to actually move a
bilateral amputee and his family were
quite difficult and we were struggling.
He had a son, he lived with his son
and the son had a problem with
alcohol dependence so we're trying to
sort of liaise with the son and get him
home, and obviously this gentleman
had no legs, had a lot of pain, he was
quite an emotional man, he was prone
to tears quite a lot of the time and we
had to move him off and you felt really
like you were abandoning him.
We moved him to another ward, which
he was fine on there, the girls on there
are really good, but it was just he'd
been with us so long and he'd had
several admissions because he's had
bypasses in the past which had
become blocked and he'd come back
and had ended up with the amputation
individual process which
informs the ethical decision
making and action
undertaken in an attempt to
resolve the problem. Charlie
explains in the account
provided how important the
individual is and that the
best interest of the patient is
paramount
The importance of effective
professional relationships
with patients, including trust,
advocacy and recognising
both the patient’s and the
nurse’s values are important
aspects of developing this
relationship (Chadwick and
Tadd, 1992).
The importance of the
relationships nurses develop
with patients in their care
Nurse: Patient
Nurse:
Patient’s family
160
and then the second one, so he was
perhaps with us 6 or 7 admissions
over the last 2 or 3 years.
Charlie: He knew he'd get the support
and help here, and it's difficult then like
I say when you move them to a
different ward. I mean he has been
discharged, he was discharged about
2 or 3 weeks ago, but you know it's
very, very difficult to say to someone
well you're the unlucky one. And you
feel it's like a lottery, you're sat there
and you're the one being chosen to do
something you don't really want to do.
Charlie: I think the other thing that I
find hard is as well, the patients get
used to us and used to the ward
environment and then you're moving
them somewhere else and I think it's a
bit like moving a child I suppose really,
you're moving them along and they
know us and it's then they've got to
form a new relationship on that ward
reflects Gilligan’s feminist
theory of moral development
(Gilligan, 1982) and the
ethic of care discussed by
Beauchamp and Childress,
(2001) and Hawley (2007).
The nurse participants
recognise that the
development of effective
relationships puts the
patient at the centre of
decision making and care
provision and thus upholds
their belief that the patient
and what is ‘best for the
patient’ is the strongest held
belief, as emerged from the
thematic analysis of the data
collected.
Charlie compares this action
Nurse: Patient
Nurse: social
care team
In partnership
Nurse: Patient
Nurse: social
care team
In partnership
In
partnership
161
you know with the staff, and I think
that's quite hard as well.
with that of moving a child,
demonstrating the sense of
responsibility of care felt by
Charlie; caring in the right
way about the right things
(Allmark,1998). This caring
relationship is the central
characteristic of the ethic of
care (Hawley, 2007),
Charlie’s Dilemma Relationships Moral Action
CHARLIE: ‘I sent one our auxiliaries
with him, I said 'make sure you unpack
his things, you know that he has a look
around the ward, introduce him to the
nurses and stuff'. I did ring the ward
up and you know said 'this
gentleman's been with us a long time,
he's had several admissions you
know, and he does know everybody,
I’m not happy about moving him, he's
not an ideal transfer. I said and I know
from your point of view because you're
colorectal, it's not an ideal patient for
us to move to you, it's not an
Charlie explains in detail the
action taken once the
decision had been made
which patient to move.
Charlie and the team
worked to make sure that
the man who was moved
was kept informed and the
move resulted in the
minimal amount of
disruption to his care.
Charlie engaged with the
nursing staff on the
Nurse: health
care team
In partnership
Nurse: health
care team
In partnership
162
appropriate move, but he's the best
gentleman to move. He was actually
the most stable gentleman we had at
that time to move, you know and I said
'he's really worried, he's quite upset', I
related all the history obviously to the
other ward, the problems with his son
and his home circumstances, the
problems we'd had with the pain team
was ongoing, and I mean I said to the
pain team was ongoing, and I mean I
said to the physios 'can you make sure
you go sort of morning and afternoon
just so he knows we haven't forgotten
him, that he hasn't been sent off
somewhere where that's it we're not
having anything to do with you
anymore.
receiving ward to explain
this man’s case and identify
his nursing needs, ensuring
that the physiotherapist
knew where he was and
making sure that he would
be seen the next day to
reassure him that he would
not be forgotten,
demonstrating the value
placed upon the individual.
.
Charlie reflects Relationships Justifying the decision
CHARLIE: Well, this gentleman had
an awful lot of problems with pain and
he had had throughout his admissions
and he has been seen by the chronic
As Charlie reflects on the
way the ethical dilemma
was addressed and the
decision making undertaken
Nurse: Patient
Nurse: health
care team
In partnership
163
pain team at home and obviously
before surgery the acute pain team,
and was seen every couple of days,
because for this gentleman it was very
difficult to get on top patients,
particularly the amputees, the
ischemic pain that they actually get in
their lower limb
is so bad prior to surgery that once
they have the amputation really they
are not bothered about the pain killers,
they are quite happy with a couple of
paracetamol, because that pain is so
bad that the wound pain they get from
the surgical wound is nothing by
comparison to what they've as with
most things, but I think that's one thing
that's really important, that our patients
are not in pain, and this particular
gentleman we really struggled to get
on top of his, so I think it was really
important that they understood that we
had a lot of problems and we had
addressed that problem but it was still
it is possible to see how the
duty based ethical
approaches were used to
justify the decision and
consequential action taken
by Charlie.
That most important value,
‘best for the patient’,
expressed by all the nurse
participants, remains at the
centre of Charlie’s account,
to which ends Charlie works
collaboratively with the
health care team and the
nurses on the ward where
the patient is going.
Charlie communicates with
the ward team where her
patient will be transferred so
that they understand his
164
ongoing.
CHARLIE: Well the thing is that he
can't go home like that because he
can't move, he can't get in and out of
his wheelchair, he can't you know deal
with activities of daily living –
he can't wash himself, he can't move
around the bed, he's got pressure
ulcers. I mean this gentleman liked to
go out for a smoke and quite often our
amputee patients will get up and
they're off the following day because
they like a cigarette, but with this
gentleman the pain was so bad he
couldn't even get out of bed which was
very, very unusual, so the pain was
extremely debilitating for this man. In
fact I can't think of another single
person actually where it's been quite
so bad as it was for this particular
gentleman, and it was, as I said, an
ongoing battle with it.
needs in order to minimise
the disruption (harm) to the
patient’s care and recovery,
indicating that the ethical
principle of non-maleficence
is upheld. The team
continue to try and manage
the patient’s pain, upholding
the principle of beneficence.
Charlie acknowledges that it
is not ideal and goes as far
as to say that moving this
man felt like abandonment.
Charlie takes the role of
caring for the patient very
strongly, so strongly that it is
expressed in comparison to
the duty of care one has to a
child.
165
CHARLIE: I think it makes you feel
like you've abandoned a child really,
you've sort of, you've just, I feel
sometimes like you know they trust us
to make us aware that we are actually
dealing with people, but yeah you
know sometimes we're treating them
like parcels because we're moving
them here, there and everywhere and I
try to make the experience....my thing
is I like to treat people how I want to
be treated and I think I would be a pain
I really do, I think I would be a
extremely difficult patient.
CHARLIE: I think I would be extremely
difficult, you know I would be very
demanding and I like to make sure that
I treat the patients the same way, so I
think you know.... as I say, I just felt, it
wasn't an experience that I wanted to
go through really. I think you have to
put it behind you and I just think, I’ve
done this, I’ve done everything that I
possibly can, there's nothing else that I
Charlie refers to the fact that
nurses are dealing with
people not ‘parcels’,
recognising the intrinsic
moral value patients have
as rational beings and the
ethical principle of
autonomy.
Charlie explains the
importance of treating
people equally, upholding
the principle of justice.
Charlie returns to how it felt
to move this man,
comparing it to the
abandonment of a child. It is
therefore reasonable to
understand how moral
distress, as identified in the
166
can do, I have to move him and that's
it, and you just have to put it in a box
and put it away, but I don't think it's a
nice feeling.
CHARLIE: Well I suppose that the
patients I’ve chosen to stay, obviously
they're in different stages of their
recovery and maybe they're not
medically stable, you know maybe I’ve
chosen them to stay, maybe they're for
surgery or whatever. Obviously I’ve
looked at all those issues before I’ve
actually moved anyone.
CHARLIE: No, I’m happy with that
because I know I’ve made the right
move, I know I’ve moved that
gentleman because I’ve no choice, it's
not a move that I’m 100% happy with
but I know I’ve done it as it should be
done you know and that's it, and you
just have to cut off from it then. That's
it, you've done what you can, you just
have to cut off and move on,
research reviewed by Corely
(2002), is a consequence of
some of the decisions and
actions Charlie had to
engage with in this
situation.
Charlie begins to justify
what has been a difficult
choice. There are targets to
meet based on the
availability of resources.
Issues associated with
minimising harm,
recognising vulnerability are
recognised by Charlie
supported by a justification
of the decision Charlie
167
Charlie: I think you can't wear your
heart on your sleeve, you can't do that.
Sometimes you just have to cut off,
you can't carry it on, because the other
thing is you've got other patients that
need you, you know they need your
expertise, they can't use somebody
who's a blubbering mess. Yeah, but I
think it's something you do have to sort
of.... you do have to harden yourself a
little bit sometimes I think.
made. This, perhaps, helps
Charlie, reduce any moral
distress experienced as part
of the moral residue which
result from any moral
dilemma (Hursthouse, 1999)
Charlie shows, some
experienced nurses have
learned to manage moral
residue and potential moral
distress by recognising the
dissonance that exists
between the ideal outcome
and the real outcome.
9.2 Conclusion
Having looked closely at Charlie’s account it is possible to identify where and how
crucial relationships with patients, their families and other health and social care
workers helped nurses to understand the impact of their actions taken in response to
ethical dilemmas. These actions aimed to help facilitate the best possible outcomes
in the context of secondary care. Experienced nurses, in this case Charlie, are seen
to recognise that the context may limit the possible options for all those on whom the
168
action may impact and that there have to be compromises made, resulting, in some
cases, in moral distress. In the account above it is possible to see how Charlie
recognised the dissonance between the ideal outcome and the best possible
outcome achievable in the context at that time, freeing Charlie of the emotional
burden of distress and possible consequences.
The overall analysis of this case study leads to a discussion, in Chapter 10,
regarding the development of the concepts in the framework, greater understanding
of the role played by moral distress and the exploration of relationships as central to
the successful resolution of ethical dilemmas in practice.
169
Chapter 10 - Discussion.
It appears from the data collected and the literature reviewed in Chapter 2 that
nurses face ethical dilemmas in practice and are in many cases able to contribute to
the resolution of these dilemmas. In this chapter I will critically discuss key aspects
of the nurse’s contribution to solving these problems and the factors that influence
their ability to do so, utilising the theoretical framework and incorporating the
findings, policy, practice, prior research, philosophy and theoretical underpinnings.
The Reconceptualised Theoretical Framework of ethical dilemmas in context (Figure
2) illustrates the centrality of relationships to the resolution of ethical dilemmas, as it
emerged from the findings in Chapters 5 to 9. This chapter will critically explore this
finding in relation to current literature regarding the stages of the framework: ethical
dilemmas in context; moral reasoning, ethical decision making; and moral action.
Whilst discussing ethical decision making it will explore the extent to which virtue
ethics are important to this relationship and the contribution this data makes to our
understanding of moral distress: In doing so the discussion will locate the study’s
contribution to nursing knowledge.
10.1 Ethical dilemmas
As discussed in Chapter 2, ethical dilemmas are those which consist of conflicting
principles resulting in equally unacceptable courses of action (Hamric et al., 2000;
Noureddine, 2001; Beauchamp and Childress, 2001). Analysis of the collected data
shows that it is possible to conclude that all participants were able to identify an
170
ethical dilemma and demonstrates that participants strongly believed that the welfare
of patients is most important; this remained a theme throughout the narrative
accounts (see Chapter 5). The dilemmas that occurred for these participants were
described in terms of the context at that time, rather than as abstract problems to be
resolved. The nurses identified their professional goal to be that their patients
receive the best care available and thus the first and possibly most important
relationship identified is that between the nurse and those to whom the nurse has a
duty of care.
10.2 The context
Obstacles to giving the best possible care and conflicts with the nurses’ personal
value systems contributed to the dilemmas discussed by participants. Examples of
the importance of context are provided within this thesis, which include the
identification of a patient who was to be moved to a non-specialist ward where care
may have been compromised or recovery delayed (see Chapter 9) and cases where
perhaps the family, or even the nurses themselves, felt that the patient’s decision
was not one they would have recommended, as discussed by Chris (see Chapter 5).
The context in which all of the narratives took place was secondary care and, as with
other societies, the secondary healthcare community follows patterns of behaviour
and formal and informal rules (Melia, 1987). Formal rules include those contained
within each of the professional codes of conduct, the law of the country within which
they practise and the policies of the organisation within which they work. Informal
rules are those which have developed through custom and practice, informal
hierarchies, many of which have been identified within the literature, especially the
171
relationship between doctors and nurses (Davies, 2003; Gunnarsdottir et al., 2009
Long- Sutehall et al., 2011).
10.2a National policy and English law
Nurse participants within this study recognised that national policy and the law
impacted on professional practice generally and, in context, the nurses were able to
identify where law applied to their practice and to the dilemmas they were facing.
For example, the Mental Capacity Act (2005) influenced the decision to ensure a
patient in the care of Chris did have capacity to make his own decision in relation to
his discharge home from hospital. The Act gave Chris a structure for thinking through
the dilemma and for arguing the case for reviewing capacity. Gillick competence
(NSPCC, 2014) was used by Ashley in caring for children, where competence to
make decisions was assessed by the nurse rather than simply accepting the parents’
decision. In both these cases the law in context supported their practice.
The National Health Service in the United Kingdom has changed significantly over
the last 20 years, with the introduction of the internal market (DH, 1990) the idea of
working with independent providers in the NHS Plan (DH, 2000), Foundation Trusts
first announced by Alan Millburn the Secretary for Health for Tony Blair’s Labour
Government of the time and Health Care Commissioning (RCN, 2011), to name just
a few of the developments. Management styles adopted by Health Service
managers, coping with limited resources, performance review and a target driven
service, have been interpreted by some as a threat to the traditional public health
service values (Dopson, 2009). This can be seen in the account provided by Charlie
(see Chapter 9) as patients are transferred to another ward due to limited specialist
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beds being available. How the ‘authority’ of doctors dominates the decision making
and limits the nurse’s ability to provide care for the dying is documented in accounts
by Chris and Charlie (See Chapter 5). Ross, too, struggled with the Bed Manager’s
decision on how to manage limited bed availability (see Chapter 7) and Nicky was
left feeling unhappy when perceiving that patient safety on the ICU was potentially
compromised as senior nurses chose to reallocate nurses to another area in the
hospital (see Chapter 7).
10.2b Organisational policy
Participants found that organisational policy restricted their ability to provide the ‘best
for the patient’ in some cases, for example when Lee collaborated with a doctor to
work outside of the organisation’s policy and prevent a patient’s transfer to another
hospital for medical consultation. Ross also refused to comply with the policy for
transferring patients due for discharge to the discharge lounge. Working outside of
the organisation’s policy may result in the employing organisation not taking
vicarious liability for the consequences of the actions undertaken by those involved,
which may lead to disciplinary measures or dismissal (for example: Blackpool
Teaching Hospitals NHS Foundation Trust; 2014; Papworth Hospital Foundation
Trust, 2014). Thus, when the participants chose, they took risks which involved a
certain amount of courage, as they might have faced serious consequences
regardless of the outcome for the patient. Courage, as a facet of virtue ethics, is
discussed in more detail below. The participants’ response to organisational policy
was also influenced by their professional Code. The ‘Code of Standards of Conduct,
Performance and Ethics for Nurses’ (NMC, 2008) was identified in the literature
173
review as important to nursing practice and reflects the values held by participants
and the standards to which they worked. The Code (NMC, 2008) is the standard by
which all nurse are judged accountable in a fitness for practice hearing (NMC, 2011).
Participants in this study did not refer to The Code (NMC, 2008) directly, although it
was evident in their descriptions of their practice. It is possible that as the nurses
became socialised into the profession, aspects of the code were internalised
(Benner, 1984; Settelmair and Nigam, 2007). The values contained in ‘The Code’
became part of their professional values, for example, ‘make the care of people your
first concern, treating them as individuals and respecting their dignity’ (NMC, 2008
p2) is evident with all participants expressing this principle in one way or another.
The internalisation of these standards adds to the concept of nursing ethics and
virtue ethics discussed below. Nurses, however, do not practice alone and the ability
to contribute is affect by the society within which they practice (Chafey et al., 1998;
Torp and Thomas, 2007).
10.2c Sociological context
Societies are made up of interconnected groups; this is reflected in the wider society
within any country, community or organisation (Porter, 1998). Hospitals reflect this
societal structure, without which the health service treatment and care could not be
delivered. The work of Durkheim (1858 – 1917), an early sociologist, focused on the
roles of social groups, for example the family, and how they contributed to the
maintenance of social structure and social laws (Porter, 1998). Health care
professions frequently work within small social groups in the secondary care setting;
these consist of a range of professionals working in a given ward or clinical area.
174
Each individual member of this group is assigned to a professional group: nurses,
medics, radiologists, and other therapists; in some cases this also includes members
of social care professions. Participants’ accounts included evidence of this
particularly between nurses and doctors (Lee, Nicky and Jo), and with other
professionals, as demonstrated in the accounts of Chris, Jordan, Charlie and Ross.
Weber (1864-1920) identified social groups by stratification rather than by class as
understood by Karl Marx (1818-83). Weber’s interpretation of social groups through
stratification perhaps reflects some of the influences on the nurse’s place within the
social context of their professional practice (Porter, 1998). Nurses fall within the final
group within Weber’s theory; these are referred to as ‘parties’. Parties have a shared
goal which is reflected in the party agenda which results in social status. Nurses
achieve this partly through the specialist knowledge and skills they achieve through a
programme of education. Equally, medical doctors have achieved social status which
appears to hold greater power than other professionals involved in healthcare
(Dierckx de Casterle, et al., 2010). It is, however, evident that with new nursing
roles, nurses show willingness to challenge doctors’ decisions regarding individual
patient’s treatment and care, as seen in participant accounts. For example, when
caring for people at the end of life, Jo and Charlie both explained that they
challenged doctors’ decisions about aggressive curative treatments (although they
were not always successful in changing the treatment plan).
The structural purpose of societies is viewed by Parsons (1937) as having two
distinct components, those which are functional and those which are instrumental.
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Functional actions are those which serve to maintain equilibrium and ensure that the
society meets its goals within the wider society, for example meeting the
organisation’s targets and the functions are those set out in the organisation’s policy
documents (Porter, 1998). Instrumental functions are those which are an end in
themselves, such as those of providing comfort to a patient, treating individuals with
compassion. Compassion can be seen in participant accounts and appears to be as
important to these participants as functional aspects of their work, demonstrated by
Charlie when balancing the benefits and burdens of transferring a patient to a non-
specialist ward (see Chapter 9).
10.2d Power
Gender also influences the place of nurses within the context of secondary care;
nursing, both historically and currently, is a profession dominated by women. Davis
(1995) suggests that men can be influenced by female cultural codes and women by
male cultural codes, each code valuing different characteristics; masculine social
codes value autonomy, power over the world and self esteem, feminine social codes
value altruism, group orientation and connectedness (Davis, 1995).
However, this is not the only power differential within the context of secondary care,
as demonstrated in Johnson’s (1997) theory of social judgment whereby the patient
remains disempowered by the context and social structures within secondary care.
Internationally, policy initiatives and the World Health Organisation (Coulter et al.,
2008) indicate that power should be transferred to the patient through patient-
centred care and the promotion of autonomous decision making. However, the
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patient’s ‘extraordinary vulnerability’ (as described by Sellman, 2011) through the
nature of their condition, the unfamiliar environment and the power health care
professionals hold through specialist knowledge, continues to perpetuate the
patient’s lack of power, whether actual or perceived. Within participant accounts it
has been possible to see how nurses try to promote patient autonomy, for example
Chris, when planning a patient’s discharge (see Chapter 5) and Jordan when
working with patients who have been recommended surgery to amputate a limb (see
Chapter 5). However, as Charlie prepared to transfer a patient to another ward the
patient had no influence in the decision to transfer, demonstrating a lack of power.
Charlie did empathise with the patient’s situation and strove to minimise the negative
impact the move might have had, using the power held as a nurse to influence
patient experiences (see Chapter 9).
Historically the nurse was portrayed as the doctor’s assistant who followed ‘his’
directions in caring for the sick (Pugh, 1944). Nursing has been associated with the
provision of intimate personal care or ‘dirty work’ and this has resulted in nurses’
position within the multi-professional team as those who do the unspeakable tasks,
which other health professionals may see as beneath them Lawler (1991).
Interestingly, none of the nurse participants discussed issues associated with ‘dirty
work’, although it is implicit in their accounts that this is part of their role. This
reflects Lawler’s (1991) research, which showed that some nurses believe that being
able to support patients with these intimate and sometimes embarrassing aspects of
care is a privileged position appreciated by those to whom they deliver this care but
that nurses rarely discussed this type of work and, when they did, it was with other
nurses.
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It is reported that the doctor makes the final decision, particularly in relation to
patient treatment (Dierckx de Casterle, 2010) but the doctor may choose to take
account of the contribution made by others. When choosing to prescribe treatment to
be delivered by others (often a nurse) who do not necessarily agree with the
decision, this can result in moral distress for the provider of the treatment (Oberle
and Hughes, 2001).
It could be concluded, therefore, that doctors have some authority over nurses,
although this is not articulated in a nurse’s contract of employment. The nurse’s line
manager is often a higher ranking nurse manager (for example: Blackpool Teaching
Hospitals NHS Foundation Trust; 2014; Papworth Hospital foundation Trust, 2014).
This demonstrates the doctor’s position of power within this context and the
limitations under which the nurse may have to work when trying to abide by The
Code (NMC, 2008). The Code (NMC, 2008) clearly states that the nurse has a duty
to challenge doctors’ orders when there are concerns that these are not appropriate.
Examples of this are seen in the accounts of both Charlie and Jo when discussing
the care of patients at the end of life (see Chapter 5).
10.2e Nurses’ role within the secondary care context.
Finally in this section, ethical dilemmas occurred in this study within the secondary
care context. Melia (1987) notes that nurses, who view nursing as a craft, help
others to do what they would normally do for themselves, striving to become
competent skilled individuals. Nursing as a profession, built on nursing theory and
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requiring both professional association and academic qualifications, results in an
increase in the nurse’s power and allows autonomous practice (Melia, 1987). This
can result in conflict and challenges to some of the historically accepted hierarchies
occurring, due to the new nursing roles and the blurring of professional boundaries
(Oberle and Hughes, 2001; Halcomb et al., 2004). The role of the nurse has
changed substantially over the last 20 years; reasons for this include the increased
technological advances in health care (Storch et al., 2004). This has occurred due to
the limited availability of appropriately qualified staff to undertake all the technical
work, in some cases previously undertaken by medical staff. Nurses have also
strived to become appropriately qualified processionals, including specialist
practitioners required to meet the needs of the service (DH, 2000; DH, 2006; Darzi,
2008). This has impacted on what organisations and individual patients expect from
nurses. These changes have resulted in a need to renegotiate professional
boundaries and, in some cases, this can be extremely challenging; nurses refer to
this as ‘working in between’ and explain how they choose their battles (Varcae et al.,
2004).
Melia (2004) identified, through sociological analysis, that in the intensive care unit
(ICU) team members, regardless of scientific knowledge or position within the
healthcare professional hierarchy, were able to contribute to the discussions during
ethical decision-making, concluding that this contributed to the smooth running of the
ICU and that the wider healthcare community could learn from this.
Within the context of secondary care the difference in the power attached to team
members and the patient’s position is difficult to justify, as all are working for the best
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interests of the patients (as well as other objectives) ( Sellman, 2011). The nurse is
in the unique position of spending more time with patients than many of the other
professionals, which may facilitate a greater understanding of the patient’s
perspective (Storch et al., 2004). Nurse participants interviewed for this study
demonstrated how, by developing and maintaining effective relationships with
patients and other professionals, they were able to empower themselves to achieve
this. They influenced others and decisions made about patient care through working
collaboratively to respect the patient’s wishes and work in their best interests.
Nurses, in some cases, needed the courage to challenge those in authority and this
conflict became evident when the nurse involved felt strongly that the alternative
suggested course of action was not in the best interest of the patient involved.
10.3 Moral reasoning
The initial critical discussion of moral reasoning presented in this thesis focussed on
a premise that it is based on the values, beliefs and expectations of the nurse.
Thematic analysis of the data collected in this study has further conceptualised the
theoretical framework, as presented in Figure 2. This conceptualisation, based on
the in-depth interpretative analysis presented particularly in Chapter 5, refers to the
theme of ‘best for the patient’ and, within this, the further sub-themes of ‘advocacy’
and ‘standards of care’.
180
Using Kohnke’s (1982) definition of advocacy as an act of loving and caring, which is
consistent with a nurse’s duty of care (NMC 2008), it is argued that maintaining the
highest possible standards of care for patients is a part of the role of advocate.
This is supported within the results pertaining to the accounts provided by those in
the managerial position of Charge Nurse. Both Sam and Brooke talked extensively
about how they worked to ensure that the standards of care provided were the best
possible; both recognised that supporting and motivating staff who, for whatever
reason, might have been perceived as having provided substandard care, would
benefit all patients as well as the staff themselves (see Chapter 5).
Nicky and Charlie, faced with limited resources, had to consider and maintain the
standards of care received by individuals and groups. In doing this these nurses
were demonstrating how they advocate for the community (Caulfield, 2005, NMC
2008), in this case, the community of patients needing care; for Brooke and Sam this
was primarily about standards of care and caring for the patient community. It is also
evident from their accounts (see Chapter 5) that they were also concerned for the
staff and, as such, were advocating in some part for the community of nurses on the
ward.
The nurse participants also believed nurses have a shared value base and are likely
to make similar decisions in similar circumstances, which supports the guiding
principles of nursing practice (NMC 2008); this is supported in the results of the
research presented (see Chapter 6).
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10.3a Collaboration and relationships.
Working effectively within a team to resolve ethical dilemmas and provide nursing
intervention within an accepted framework of central practice policy supports the
sub-theme identified as ‘moral action’. The nurse’s contribution to the resolution of
ethical dilemmas in the context of secondary care is facilitated through the
relationships they choose to build and maintain. These relationships are identified by
Peter and Liaschenko (2013) as central to morally correct culture and context and
embrace the core aspects of moral agency, identities, relationships and
responsibilities. Participants’ accounts highlighted the importance of these
relationships in achieving moral action, as discussed below.
10.3b Nurse patient relationship
The most significant factor to emerge from the data was the importance of
relationships to moral reasoning and moral action.
The first and most important relationship identified within the reconceptualised
theoretical framework is that between the nurse and the patient, for example, Jo and
Charlie when supporting patients and their families at the end of life; Ross and Chris
when discharging a patient home after a hospital stay; and Lee when negotiating
care for a frail older person. Entering into this relationship both demonstrates the
nurse’s commitment to that individual and requires the nurse to invest in its ongoing
maintenance. The idea that care given in the nurse-patient relationship is not
reciprocated with a similar level of care is highlighted by Barnes (2012) and Melia
(2014) who recognise that relationships in the care process are complex, particularly
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where the care is provided by a paid carer. Within this ethical relationship, involving
trust and compassion, the difference in power between the nurse and patient is one
that has the potential to result in those most vulnerable being neglected or abused.
Poor standards of care were recently highlighted and a detailed review of poor
standards of care within the Mid-Staffordshire NHS trust was undertaken; the report
identified where these relationships may break down (Francis, 2013). This has
resulted in a call for the recruitment of student nurses to be value based and a
review of the number registered nurses within clinical areas (Nursing and Care
Quality Forum, 2012).
The care of the vulnerable, frail or unwell is recognised within the Ethic of Care as
involving a collective responsibility and therefore requiring nurses to maintain a
number of professional relationships (Barnes, 2012), identified within the
participants’ accounts of both Ashley and Chris (Chapter 5). In the accounts where
this collective responsibility failed to support what the participants perceived to be
the most appropriate course of action, participants became dissatisfied. In some
cases participants worked outside organisational policy when this had the potential
to support the preferred, less harmful option, circumventing obstacles and meeting
the collective responsibility, professional duty and personal decision to provide care
and this was clearly demonstrated in the accounts provided by both Lee and Ross.
It has been debated that care has different meanings in different contexts (Almark,
1998; Banks and Gallagher, 2009). In this case I use the term ‘care’ to be something
that occurs when the needs of another generate concern and compassion for that
‘other’, which may explain the initial desire to care (Banks and Gallagher, 2009).
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However, caring in the ‘right’ way, about the ‘right’ things, as discussed by Almark
(1998), as one who promotes the patient’s wishes and advocates through patient
empowerment can be difficult due to the barriers identified within this thesis, which
include working with limited resources (Vaartio and Leino-Kilpi, 2005), understanding
and respecting the beliefs and expectations of others (Banks and Gallagher, 2009:
Barnes, 2012) and balancing the needs of others (In this case patients and clinical
areas) (Barnes, 2012). This type of care requires energy, commitment and ability by
those providing care to understand the culture of those to whom they provide care
and the context within which care is provided (Banks and Gallagher, 2009). This
was evident in Chris’s account when caring for a vulnerable patient whose capacity
to make decisions was questioned by his family. All participants referred to patients’
needs and values, for example the wish perhaps not to have life prolonging
treatment in the last days before death or not to have a limb amputated at the advice
of a surgeon.
The ‘Ethic of Care’ recognises the importance of supportive relationships from a
variety of contexts, for example in friendship, the family or the state. Nurses fall into
the classification of those paid to provide care (Barnes, 2012). Considering the
relationship when giving informal care it is evident that caring is a practical and
emotional process; this may not be the case where there is an obligation to provide
care through a contract of employment (for example: Blackpool Teaching Hospitals
NHS Foundation Trust; 2014; Papworth Hospital Foundation Trust, 2014). Ethical
relationships are recognised as essential between nurses, patients and others
involved in patient care; the nurse-patient relationship is embodied in advocacy and
the provision of care (Varcoe et al., 2004). It is important to recognise the risk of
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coercion within these relationships and nurses are encouraged to be self aware and
practice reflectively to reduce the risks of this occurring (Barnes, 2012). In Chris’s
account the risk of coercion is acknowledged and, to reduce this risk, Chris called in
Social Services to assess and support the patient concerned in making his own
decisions about his future care by presenting appropriate information about his
options.
The Ethic of Care, which focuses on the importance of ethical relationships, may go
some way to explaining the nurse’s role as moral agent and how nurses contribute to
the resolution of ethical dilemmas in the context of secondary care. It is, however,
apparent from this study that it involves more; the relationships are the facilitator of
understanding the dilemma and facilitating moral action.
Choosing to become a nurse and provide care, nurses engage in relationships with
those who are vulnerable, or ‘more-than-ordinarily vulnerable’ as Sellman (2011)
defines the vulnerability of those who are in need of nursing care. Through this,
nurses demonstrate that the patient is valued as an individual and that decisions
made and subsequent actions taken by the nurse will be undertaken to reflect this.
The findings of this study have demonstrated that nurses hold shared values which
are reflected in The Code (NMC 2008). It is also evident from the data that the nurse
participants demonstrated a number of virtues which impacted on their decision
making and actions.
Initially participants indicated concern about a patient in a given situation; nurses are
referred to as caring for patients, care however is not recognised by all as a virtue
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(Allmark, 1998). The nurses interviewed demonstrated how they cared about the
patient(s) in the accounts provided. Participants deliberated over what was the best
course of action, weighing up the options, using knowledge gained through
experience and the acquired wisdom to use that knowledge in a way to promote
effective practice. Ashley explained how less experienced nurses recognised this
and would call on him for guidance, demonstrating that less experienced nurses
were able to recognise the ability to understand and identity appropriate responses
to complex ethical dilemmas.
10.4 Ethical decision - making
What is evident from the analysis of the nurse participant accounts is that nurses use
the language of consequentialism and deontology to justify some of the actions
taken, however it is virtue ethics that is the dominant model used in the accounts
collected in this study.
Virtues have been identified by moral theorists (Gilligan, 1982; Aristotle, 1998; Tong,
1998; Noddings, 2003) as character traits which are constant, thus defining people
by their innate qualities rather than by their actions. Character traits include both
virtues and vices, on a continuum where extremes are considered to be undesirable.
Aristotle (1998) views some virtues as universally desirable; whilst some are
considered more important or especially required in specific contexts. For nurses,
virtues might include trustworthiness, honesty and loyalty (Armstrong, 2007). Open
mindedness may also be a virtue in nursing (Sellman, 2011) as nurses are required
to be able to understand the perspectives of others in addressing the ethical
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dilemmas they face in everyday practice and considering with respect the values and
beliefs of others.
Nurses are also said to need to be knowledgeable, behave accordingly and
demonstrate the Chief Nurse’s 6C’s of Nursing, which indicate nurses should be
caring, compassionate, courageous, competent, committed and communicative
(Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser, 2012).
Whilst not all of these may be defined as separate virtues, they fit well with a virtues-
based approach.
In order to manage the continuum between virtues and vices it is argued that all
character traits must be mediated, as per Aristotle’s (1998) median. For example,
nurses need to find the right balance between being courageous or cowardly when
deciding how far to defer to those who appear to have more authority when working
with patients and their families. In the participants’ accounts challenging and
managing authority figures occurred with the matron (Nicky), the bed manager
(Ross) and the doctors (Jordan), or in a foolhardy way, without regard to all those on
whom the situation and resolution might impact (Charlie). All these accounts
demonstrate the nurses’ rationale in trying to resolve ethical dilemmas but is
especially clear in Charlie’s account, in Chapter 9, where the situation, decision
process and resulting actions are presented as a single case study.
In order to manage the balance, or median, ‘practical wisdom’ is seen as an
overarching virtue. For example, honesty may be seen as a desirable virtue for
nurses, however the excess might involve a level of outspokenness which is
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delivered without the ‘reasoned qualification’ provided by wisdom (Hursthouse,
1999).
Limitations to this approach are discussed comprehensively by Armstrong (2007)
who recognises, as did Aristotle and others, that an excess or deficiency of character
traits defined as virtues can lead to care that is not always ideal.
The nurse participants demonstrated that they were concerned about those in their
care. In order to ensure that patients within this context were safe and adequately
cared for, it is argued that the nurses often used the language of virtues to explain
their thinking and actions. Virtues that appeared common to the role of the nurse
included compassion, honesty, courage, empathy, open-mindedness and
trustworthiness. Compassion and empathy were demonstrated by participants who
discussed, with some insight, the situation and its impact on the patients within the
dilemmas they chose to recount. Honesty appeared overtly in the accounts
presented by Lee, who also had the courage to work outside the organisation’s
policy on oral drug prescriptions, in recognising that the second choice drug might
not work to manage the patient’s pain and the patient might still need to be seen by a
physician. Courage was also demonstrated by Drew who chose not to give sedative
medication when instructed to by a senior nurse, having the courage to stand by her
own judgements, and also by Ross who did not move patients into the discharge
lounge as this was regarded as inappropriate for the two particular patients within the
account provided in this study.
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The virtue of trustworthiness was demonstrated within participant accounts as they
demonstrated how they went about achieving the best possible outcomes for the
patients in the accounts.
Within virtue ethics it is recognised that to be truly virtuous one needs to have
knowledge and wisdom to facilitate the appropriate application (Hursthouse, 1999).
Nurse participants were able to explain why they acted as they did and were able to
identify the values that underpinned the decisions which informed their actions. The
wisdom, acquired through practice experience, was recognised by junior, less
experienced, nurses within Ashley’s account, where junior nurses sought advice and
support from those with more experience.
10.5 Moral action
Within the context and concept of the major theme of moral action presented in this
thesis, and supported by the results, are subthemes which have resonance with prior
authority and critical debate. These are notable and receive critical discussion, and
location, in this section, related to ‘collaboration’ (Carter 2009; Sanders 2009),
‘advocacy’ (Kohnke, 1982; Hyland 2002; Hawley, 2007; Cuthbert and Quallington,
2008) and ‘accountability’ (Savage and More, 2004; Caulfield, 2005; Ormrod and
Barlow, 2011). The results presented and interpreted in this thesis support the
premise that, to achieve positive outcomes, nurses have learned that developing and
maintaining professional relationships within the context of the secondary care
setting is central to enabling them to contribute effectively. Having developed
effective relationships with the people in their care (see 10.3b above), participants
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explained how important it was to work inter-professionally to achieve the best
possible outcome in the ethical dilemmas discussed.
10.5a Interprofessional working
It has been acknowledged that interprofessional teams appear to work more
effectively within care of the older adult, where many of the patients have complex
needs (Carter, 2009). Interprofessional working is effectively articulated by Chris,
who worked with the patient, his family and a multi-professional team from both
health and social care (see Chapter 5). Lee also worked collaboratively with medical
staff to ensure that the patient received the medication required to treat an infection
without the added trauma of moving hospital sites. As Lee explained, in some cases
the doctor involved did not actually know the nurses requesting the verbal order for
medication; the trust between the two professional groups is something that appears
to have become part of the culture within that particular environment. However,
participants also explained how conflict could occur when doctors and nurses had
different ideas about what needed to be done in a particular situation. This was
clearly articulated by both Charlie and Jo when discussing the care of a terminally ill
patient, with the doctors’ mandate to care dominated by the intention to cure, the
nurses in these accounts explained how they felt the correct course of action would
be to maintain comfort and dignity and reduce suffering (see Chapter 6).
The nurse’s role within the multi professional team is diverse and can take a number
of forms depending on the situation and context; these include care giver and
coordinator; autonomous practitioner; team member; team leader; and nurse
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specialist (Sander, 2009). Within secondary care, situations can and do change
rapidly; care often involves large numbers of people from a variety of professions,
health and social care, as well as the patient and their family and carers (Carter,
2009). This thesis supports the collaborative nature of nurses working within teams
to resolve ethical dilemmas and presents a theoretically underpinned understanding
of collaboration which encompasses concepts of the complex relationship between
embedded cultural and conflicting professional drivers (Lamb & Sevdalis, 2011;
Long- Sutehall et al., 2011).
Effective collaboration has been identified within this study as important to achieving
the moral action required to meet the needs of those on whom the dilemma could
impact. Within the current literature collaboration has been identified as contributing
to high standards of care (Finkelman and Kenner, 2010), improving patient outcomes
(Faulkner and Laschinger, 2008) and as an objective of the National Health Service
in the United Kingdom (Torp and Thomas, 2007). Working in a cohesive environment
has also been shown to increase job satisfaction amongst nurses (Adams and Bond,
2000). A nurse’s role within decision making may involve advocating for those who
are unable to advocate for themselves or promoting self-advocacy in the vulnerable
by providing support and information (Hawley, 2007)
10.5b Advocacy
This section critically discusses the issue of advocacy that is related in the
participants’ narratives and is located within the literature in terms of definition,
concern, nursing attributes and codes of practice (Caulfield, 2005; NMC, 2008).
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Advocacy is not a new concept but one which has been embedded in nursing
practice for many years (Abrans, 1978; Kohnke, 1982; Chadwick and Tadd, 1992).
Kohnke’s (1982) classic text refers to advocacy as an ‘act of loving and caring’ and
includes providing patients with the right to information to facilitate self-determination
with an emphasis on patient safety and wellbeing. Previously the view has been
presented that nurses are only able to advocate if they ‘care’ about the patient and
failure to care would result in advocacy being a purely mechanical process (Vaartio
and Leino-Kilpi, 2004). It is argued, however, that advocacy is not straightforward;
not all nurses are able to advocate effectively and it is suggested it can be learnt,
developed and applied in practice (Kohnke, 1982). Ashley explained how less
experienced nurses would come for advice and to discuss complex cases in order to
benefit from the experience and knowledge held by those who had been practising
for many years, in Ashley’s case in excess of 30 years. Empirical work undertaken
by Chafey et al., (1998) identified that nurses can advocate effectively although, at
times, conflict can occur between nurses and other health professionals, resulting in
a significant amount of stress within this role.
Advocacy appears to consist of providing information to support patients’
autonomous decision-making and, where capacity is compromised; the activities
associated with advocacy include protecting the patient’s rights and those of
safeguarding (Kohnke, 1982; Vaartio and Leino-Kilpi, 2004). Kohnke postulated,
and is supported by this thesis, that to be a competent advocate nurses require
special attributes; the advocate must have a sound understanding of their own
values and beliefs to allow them to recognise those of the patient without necessarily
sharing them (Kohnke, 1982); the advocate needs to be open-minded to facilitate
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effective listening to understand the patient’s wishes, open-mindedness also ensures
that the nurse can present information objectively to the patient without the nurse’s
personal values affecting the information provided (Kohnke, 1982). Nurses, over
time, develop some of this through the process of reflection, as suggested and
recommended by Schön (1987) and Johns (1995) as a way of developing practice.
The idea that reflection is crucial to the development of personal and professional
practice and standards of care is further discussed by Hargreaves (2013) to
emphasize the importance of interprofessional, shared reflection to appropriately
develop collaboration in the development of supportive practice to achieve high
standards of patient care.
It could be argued that the model of nurse advocacy has changed little from that
defined by Abrans (1978) as one who ensures that the patient receives a high
standard of care. However, advocacy can be viewed as passive; one who accepts
the patient’s viewpoint and decisions and delivers care that is available in the current
context of organizational policy and philosophy (Hawley, 2007). In this thesis it is
further suggested that the active advocate will deliver care based on professional
standards and what the individual believes is the morally right action. This is
supported in the accounts provided here by Ross, who refused to follow policy and
move patients who she felt would suffer as a consequence of a move to the
discharge lounge and by Lee, who ‘bent’ the rules to ensure the patient received the
drugs required for treatment of an infection without the trauma of transfer to another
hospital. This adds to the critical debate that advocacy, within a framework of moral
action, is constituted by the nurse’s sense of what the morality of the action is in their
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view, even when convention or ‘societal’ (practice) rules state that this would be
deemed incorrect (Ulrich et al., 2010).
In their critique of different models of nurse advocacy Chadwick and Tadd (1992)
emphasised that nurses should possess the attributes and knowledge with which to
advocate appropriately and recognised the powerful position of the nurse in the role
of advocate, particularly where patients are vulnerable through their lack of
understating of the situation or due to the nature of their condition, whether acute or
long-term. Chadwick and Tadd (1992) construct a strong argument against the
nurse as advocate, suggesting that an independent advocate is better placed to take
on the role of patient advocate, emphasising that the nurse’s duty of care to others
results in the nurse being unable to advocate wholly and impartially for the patient
due to the conflict of interests this presents.
Another barrier to effective patient advocacy by the nurse is due to the potential
conflict within the multidisciplinary team (Chadwick and Tadd, 1992; Melia, 2014).
However, as nurses spend more time and develop closer relationships with the
patients, others argue that nurses make appropriate patient advocates (Storch et al.,
2004). As discussed in this study by Jordan, such conflict may result from nurses
supplying information to patients that others, for example health professionals and
family, may prefer them not to have (Kohnke, 1982).
To some extent the nurse is required to act as an advocate for the community; this
community could be a ward or unit, as in Nicky’s account of the struggle to keep all
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the registered nurses on the intensive care unit rather than releasing one to work in
another clinical area and for Charlie, who was trying to balance the needs of the
patients on the ward and those waiting to be admitted. For Jordan it involved trying
to develop best practice, promoting the wellbeing of all potential patients
recommended to undergo a limb amputation, supporting Barnes’ (2012) presentation
of advocacy. These accounts demonstrate that attributes required to be an effective
advocate include the ability to communicate appropriately with patients to ensure
that their needs and wishes are fully understood and open-mindedness in order to
remain non-judgmental about the decisions and wishes of others which may not
match the nurse’s personal values or may appear foolish in some way (Hawely,
2007).
10.5c Accountability
Accountability also threaded through the nurse participant narratives collected for
this study; this was demonstrated through their awareness of consequences of
actions and their willingness to stand by their decisions. This supports the work of
Hood and Leddy (2006) which conceptualised perceptions of accountability in terms
of punishment or as an empowering process. The concept of accountability was
strongly held by all participants and recognised as punitive and empowering, seen
clearly in the account provided by Ross when challenging the instruction to move
patients off the ward in preparation for discharge, when Ross had considered this not
to be in the best interests of these particular patients. Ross was clear that the
decision to keep the patients on the ward was correct and justifiable, whilst
acknowledging that having refused to do as the Bed Manager asked resulted in a
feeling of unease. Accountability for the participants involved justifying their position;
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based on these findings it can be argued that accountability is complex for the nurse
whilst the empowering aspects help nurses function as autonomous practitioners.
The nurse’s position within the context of a hospital setting can prove demanding
and may leave the nurse feeling uncomfortable when challenging the views of other
health professionals, who may perceive themselves as more knowledgeable or
powerful than the nurse (Caulfield, 2005; Hood and Leddy, 2006).
The decision to act is not something these nurses do in all cases; the decision to act
courageously to support the patient’s ‘best interest’ is informed by compassion,
meaning the ability to recognise the vulnerability of another and advocate for them
as needed. It is possible to see from the participants’ accounts that the patients
within the incidents discussed are those who are more vulnerable, for example those
who are dying and are disempowered by their condition. Charlie and Chris (see
Chapter 5) both explained how sometimes there is a need to discuss palliative care
rather than aggressive treatment, when patients are nearing death. Palliative care
may be what the patient would want at this time. The relationships nurses develop
with patients and patients’ families place them in an appropriate position to begin to
understand their expectations, through discussions over the care period (Storch et
al., 2004).
10.5d Relationships
The participants explained how they managed working effectively in the hospital
setting, as far as they could, by developing trusting professional relationships within
the team. In this study such relationships are presented as significant in the
understanding of ethical decision making, however, there were times when the
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participants felt let down or disappointed by others when their perspective on the
situation differed from those in a position to take away the nurse’s ability to act
autonomously. Participants in this study gave examples of when this was effective
and when it was not as they would have hoped. Positive experiences are discussed
under `Collaboration` in Chapter 7 and these less positive experiences in Chapter 7
under the heading `Conflict`. Where conflict occurred this had the potential to impact
on the nurses’ experience of moral ‘residue’, as discussed below.
Notwithstanding the limitations of professional relationships described by the
participants, what has been demonstrated in this study is that ethical relationships
are crucial to facilitating the nurse’s contribution to meeting patients’ needs and
addressing ethical dilemmas in the context of secondary care. In addition, this
relationship, whilst initially appearing to have ethics of care at its heart, is
strengthened by the cultivation and use of the virtues of compassion, honesty,
courage, empathy, open-mindedness and trustworthiness (Hursthouse, 1999;
Armstrong 2007; Hawley, 2007; Selman, 2011; Barnes 2012; Commissioning Board
Chief Nursing Officer and DH Chief Nursing Adviser, 2012).
10.6 Moral residue
Hursthouse (1999) divides moral dilemmas into ‘resolvable’ and ‘irresolvable’
dilemmas and indicates both may result in moral residue or some kind of remainder
(Hardingham, 2004). This is apparent even when one moral principle clearly
overrides another, for example when Drew was instructed to administer sedation to a
patient and when Lee took verbal instructions to administer patient medication. Both
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recognised they had engaged in a morally right action, however, they had worked
outside custom and practice in Drew’s case and organisational policy in Lee’s case.
Moral residue is descriptive of the way they felt in these circumstances (Chapter 7).
Moral distress is delineated within prior literature (Oberle & Hughes, 2001; Aroskar,
et. al., 2004; Hardington, 2004; Kalvemark, et al., 2004; Kain, 2007; Rodney, 2013;
Musto et al., 2014) and the participant accounts collected for use in this study. Moral
distress is discussed earlier, in Chapter 2, where I highlight how moral distress was
experienced by nurses expected to deliver care that they did not agree with or felt
the patient might not want. This was narrated by both Jo and Charlie, where dying
patients were considered to have received aggressive treatment that was considered
by the patients’ families and the nursing team to be futile and possibly prolonging
patient suffering.
Moral distress has also been identified when nurses find they are not able to deliver
the standard of care they feel is best for the patient, due to the context in which they
are working, including limited resources (Oberle and Hughes, 2001; Colebatch,
2009). This was evident in Nicky’s account, where nursing staff were moved from
the intensive care unit to provide care on another ward that was short of qualified
nursing staff (see Chapter 6). Such circumstances left Nicky and the team
susceptible to experiencing moral distress or residue if unresolved; this can have a
cumulative or crescendo effect and may result in the individual nurse reaching
breaking point (Epstein and Delgado, 2010)
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It could be argued that moral distress appears to be a consequence of the decision
to invest oneself, as a nurse, in caring relationships with patients and respectful
relationships with others such as colleagues and relatives. Nurses choose their
profession and invest energy and emotion in these relationships. This can be seen
in each of the participant accounts as they explain how they considered the patient’s
best interest first and foremost. Charlie acknowledged the importance of the
relationships and explained how much information was shared with the nurses
reviewing a patient transferred to a new area to help new relationships to develop
effectively. Drew, although uncomfortable, felt a responsibility to advocate for the
patient and protect him from being unnecessarily sedated. Lee took risks working
outside the organisation’s policy to ensure that the patients received high quality
care. In each of these examples nurses put their professional standing with
colleagues at risk in considering the patient’s needs, a price only Lee acknowledged
explicitly, all the other participants acknowledged this when showing they were ready
to be called to account. These dilemmas were resolved; however it is evident that,
as indicated, nurses did experience some moral distress. The participants
expressed the following emotional responses to the situations they chose to discuss
and these included:
‘I was very frustrated by the whole thing’. Drew
‘it makes you feel like you've abandoned a child really, you've sort of, you've just, I feel sometimes like you know they trust us to make us aware that we are actually dealing with people’ Charlie
‘I feel torn between two decisions to be made – there is something uncomfortable and you are thinking have I done the right thing or haven’t I done the right thing’. Lee
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‘.....really felt berated, I really felt like I was just being militant and I was being obstructive and I wasn't, so it was very difficult’. Nicky
Moral distress may have serious consequences for the individual, those who come
into contact with the health services as a user or carer and the nursing profession.
Musto et al. (2014) identified that nurses may contribute to the maintenance of the
organisational structures that limit their contribution by, for example, engaging in the
belittling of junior staff and failing to appropriately support nurse managers. As a
consequence of moral distress nurses can become ‘burnt out’, desensitised to the
situations that have resulted in the moral distress, as a way of coping and, in some
cases, nurses may leave the profession altogether, which leads to a loss of valuable
resources in experienced personnel (Corley, 2002; Hardingham, 2004; Ulrich et al.,
2010; Palvish et al., 2011).
Nurses may also contribute to their moral distress by not taking the opportunity to
respond appropriately, thereby failing to recognise the positive aspects of moral
distress and the potential for change (Musto et al., 2014). Participants with extended
years of experience, Charlie and Ashley, demonstrated how they were able to
manage moral distress and rationalise the differences between the ideal and reality
using reflection in and on action (Schön, 1987).
Recent work has resulted in the understanding that the negative impact of moral
distress is not the only result (Hardingham, 2004; Laabs, 2007). Moral distress can
be empowering and it has been suggested by Hardingham, (2004) that it may be the
catalyst for practice development. Nurses may use reflection on the event which has
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caused feelings of unease or distress to help them identify the causes and ways to
change practice or build an ethical organisational culture. This would then have the
potential to develop practice and improve both the patient’s experience and
standards of care (Holloway and Freshwater, 2007).
‘I feel if we didn't have challenges like this it would be.... I don't think we'd ever develop, but also I think we'd become very complacent and think 'oh everything's fine on here....’ Ross
Irresolvable dilemmas are those in which the agent has a choice of actions and each
is unacceptable (Hursthouse, 1999). Chapter 9 indicates how Charlie addressed
what could be seen as an irresolvable dilemma as the move was not in ‘that’
patient’s best interest but the best interests of ‘another’. Charlie, however, found a
way to manage the moral residue, recognising the dissonance and accepting that
any resulting impact on the patient being moved was minimised through effective
interprofessional working and maintained through effective working ethical
relationships. This prevented Charlie from experiencing the potential negative
consequences of moral distress. Perhaps what was expressed by Charlie is moral
dissonance rather than distress. The ideal ‘gold standard’ which Charlie and other
participants would like to deliver is not always attainable; this may be due to
restrictions which are to some extent outside of their control (Ulrich et al., 2010).
In addition to validating some aspects of earlier work on moral distress and moral
residue, the findings in this study contribute new insights. They reinforce the
possibility that moral distress may be a catalyst for action, rather than be an
inevitably negative experience and that moral residue, mediated by reflection in and
on action, can positively improve decision making.
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10.7 Conclusion
It is observed from the findings that the nurses working in the secondary care setting
recognised the moral issues within their daily practice. The nurse participants
demonstrated how they attempted to meet the needs of the patients within their care
and how they developed effective relationships with patients, their families and other
health care professionals to facilitate the best possible outcome for these patients
within the context of secondary care. Aristotle’s virtue ethics best explain how
nurses view and respond to the dilemmas they face in secondary care, however,
because of the context, there is some reference to utility as nurses only have access
to limited resources. Participants approached dilemmas compassionately, with the
patient’s well being at the forefront and approached their role flexibly, with an open-
mind, in order to achieve the ‘best possible’ outcome. This, on occasion, required
the nurses to have sufficient courage to challenge those in more powerful positions
than themselves. Their ability to achieve the desired outcome could be based on
ethical relationships fostered by nurses with patients, their families and other health
and social care professionals. In maintaining these relationships it appears that
nurses are able to undertake moral action as depicted in the (re) conceptualised
theoretical framework in Figure 2.
Challenges occurred for these participants when they found themselves in conflict
with other health professionals and the organisation’s policies, or lacked the
resources to ensure best practice was achieved. When nurses were unable to
negotiate a satisfactory outcome, some experienced moral distress or moral residue.
The participants Ashley and Charlie, both of whom had approximately 30 years
nursing experience, appeared to have developed ways of mediating this distress and
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using it positively, by acknowledging the moral dissonance which occurs when what
may be hoped for is not achieved and recognising that there are limits to what is
achievable within the context they are working.
Nurses in these accounts achieved moral agency, resulting in moral action, through
the relationships they developed. The virtues possessed by individual nurses may
explain why they chose to engage in these relationships as they did and to act as
moral agents.
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Chapter 11 - Conclusions
11.0 Introduction
Chapter Eleven reviews the aims and objectives, demonstrating that they have been
met and highlighting the contribution to nursing knowledge which has been identified
within this thesis. Limitations of the study are acknowledged and recommendations
are made for nursing practice. Further research into nursing values and ethical
decision making, including the moral distress experienced by nurses, is suggested. A
comprehensive reflection on the process identifies the journey experienced and my
growth in research skills and insight into the subject of ethical dilemmas in nursing
practice.
This research had the aim to identify the values, beliefs and contextual influences
that inform decision making and the contribution made by registered nurses in
achieving the resolution of ethical dilemmas in nursing practice. Throughout the
thesis four objectives have been addressed:
5. To identify underpinning values and beliefs which impact on nurses’ ethical
decision making and moral action.
6. To critically discuss new themes which are generated from the data in the
light of current literature.
7. To identify the contextual influences which impact on nurses’ ethical decision
making and moral action.
8. To discuss the implications of the study findings for future nursing practice.
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Through a review of the literature in Chapter 2, aspects of ethical decision making
were identified. Analysis of the collected data (Chapters 4 to 9 ) developed thematic
understanding; this included the nurses’ desire to do ‘what is best for the patient’
(Hawley, 2007; Darzi, 2008; Maben and Griffin, 2008); accountability (Caulfield,
2005; Hood and Leddy, 2006; NMC, 2008); collaboration (Botes 2000a; DH, 2008;
NMC, 2008; Johnson and Webber, 2010); and conflict (Oberle and Hughes, 2001;
Torjuul and Sørlie, 2006; NMC, 2008), which has the potential to result in moral
distress (Corely 2002; Gallagher, 2010) and concern for others (Cummings et al.,
2010).
Content and interactional analysis was undertaken to inform the contextual
influences and how findings of the thematic analysis informed what the nurses
contributed when faced with ethical dilemmas. Through this detailed exploration of
the data the theoretical framework presented in Chapter 1 has been explored,
leading to a re-conceptualisation in Chapter 9.
Analysis of the data collected from nurse participants demonstrated that by
developing and maintaining effective therapeutic relationships with patients and their
families, nurses perceived that they were in a good position to understand the
patients’ wishes and needs and, in some cases, the wishes and needs of the family.
Other health care professionals may also do this; it is, however, the extensive time
that nurses spend with patients during their hospitalisation that places nurses in this
position (Peter et al., 2004; Storch et al., 2004). The nurse’s relationship with the
patient and their family places the nurse in an appropriate and perhaps unique
position to promote patient autonomy and, when required, to act as a patient
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advocate. This makes the nurse’s contribution to addressing ethical decisions an
important aspect of inter-professional working.
It is apparent in the findings that nurses make complex decisions in the practice
setting, though they may not always be able to act according to their wishes. Whilst
nurses have both a wish and a professional responsibility to advocate for patients in
their care, there are a number of constraints and other people who need to be
considered; compromise is then required. This is illustrated by the narration detailed
in Charlie’s case in Chapter 9.
11.1 Contribution to nursing knowledge.
11.1a The findings of this study offer an in depth qualitative exploration of the
decision making processes used by nurses in secondary care when attempting to
resolve ethical dilemmas. The emergent themes add to our understanding of the
ways in which acting in the patient’s best interests or putting the patient first affects
nurses’ decision making.
11.1b The conceptual framework outlined in Chapter 1 suggested ethical
approaches that might guide nurses’ thinking. The findings suggest that the concepts
within virtue ethics, in particular courage and honesty, may be significant attributes
for nurses to develop. In addition, the findings suggest a re-conceptualisation of the
framework (see Chapter 9) to include the centrality of relationships.
The fundamental importance of professional relationships emerges from the data
and, whilst relationships with patients are the initial priority, it is essential to have
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highly developed interpersonal skills, including communication, to enable nurses to
build and maintain professional relationships with a variety of people. The dilemmas
shared by participants demonstrate that the nurse needs to negotiate, share
communicate and collaborate with many other people in order to try to get what they
see as the best outcome for their patient
11.1c Moral distress was identified within the literature in Chapter 2 and this, as well
as moral ‘residue’, is evident in the participants’ narration of their experiences.
Corely (2002) offers a framework for understanding moral distress that gains some
validation from the participant accounts. They shared their experiences of how they
tried to maintain the patient at the centre of care in line with their moral values, their
education, their professional code and policy recommendations from The Mid
Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013) and Compassion
in Practice (Commissioning Board Chief Nursing Officer and DH Chief Nursing
Adviser, 2012), as well as working in the context of service-led health care provision
limited by the available resources and the requirements to meet government-set
targets. Moral distress continues to be a problem for both nurses and other
members of the health care profession. Gallagher (2010) recognises that staff
shortages, failed attempts to advocate and the developments in delivering care are
the main causes of moral distress, all of which are supported in participants’
accounts in this study. Gallagher discusses three cases highlighting the need for
nurses to show moral courage; this was demonstrated in the accounts of Ross and
Drew where they needed to highlight failures in care standards.
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However, the findings also add to the suggestion by Hardingham (2004) that moral
distress could also be a catalyst for guiding decision making. In particular, in their
accounts Charlie and Ashley show how they used reflection in and on action to
channel their ‘distress’, using it to guide action. Rather than conceptualising moral
distress and its residue as a ‘negative’ outcome of ethical dilemmas, it may be better
understood when embraced as a guide to action throughout the decision making
process.
11.2 Limitations of the study
It is essential to recognise the limitations of any research study; without insight into
limitations the researcher or interpretation of the research presented may be over
optimistic (Polit and Beck 2008; Burns and Grove, 2009). For the interpretation of
the research findings to be realistic and therefore believable, the limitations have
been identified:
1. Data has been gathered from nurses working within a single Trust and the
organisation culture may impact on what nurses do; organisational culture
may vary from one NHS Trust to another. Those working within that Trust,
especially those who have lived in the geographical locality, may reflect the
values of the local culture internal to the practice setting rather than the
population of registered nurses working in Britain and this therefore may affect
the transferability of the findings (Burns and Grove, 2009).
2. The issue of sample size within qualitative research was critically discussed
in Chapter 3 of this thesis. Despite asserting that the range of the narratives
and the quality of the data from the 11 participants is sufficient, this is worthy
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of inclusion as a limitation. The judgement to stop at 11 participants was
based on the researcher’s experience in the field of enquiry, the context of the
sample setting and the depth of data collected. As the interviews undertaken
provided sufficient data to meet the study aims and objectives, it was
considered satisfactory. However on reflection, it could be that in future further
explorations and expansions of this thesis’ contribution, a wider and larger
sample would be required to establish representative perceptions in the
nursing profession.
3. The participants were all self selected and therefore may have had a
disposition that recognised the importance of ethical dilemmas and an
awareness of the nurse role in their resolution (Polit and Beck,. 2008).
4. The researcher’s own experience as a Registered Nurse may have had an
influence on the interpretations of the data collected (Parahoo, 2006; Polit and
Beck, 2008).
11.3 Recommendations
11.3a Recommendations for nursing practice
Having completed this exploratory study, it is evident that whilst nurses do have a
role in resolving ethical dilemmas in practice, there are still a number of outstanding
areas to be addressed to ensure that this is maximised.
Based on the analysis of the participants’ narrative accounts, those nurses
interviewed had a value system which is reflected in the NMC (2008) Code and the
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patients’ experience was their primary priority when faced with ethical dilemmas. It is
therefore important that nurses are aware of The Code (NMC, 2008) and consider if
the professional values within it reflect their personal values, because where there is
conflict nurses may struggle to manage the moral distress that they may experience.
Nurses need to be able to communicate effectively to develop and maintain the
professional relationships required to achieve effective advocacy. The case study
presented in Chapter 9 and the conceptualised theoretical framework (Figure 2)
highlight the importance of the relationships nurses had with others in the
contribution these nurses made in addressing ethical dilemmas. It is therefore
important that nurses have the opportunity to develop advanced interpersonal skills.
Nurses need to be able to influence both micro and macro decision making within
health care organisations. Nurses need to begin to take every opportunity to
contribute to the development of national and organisational policies which inform
their daily nursing practice and the management of organisational resources. Nurses
therefore require the courage and the self confidence to engage with others at all
levels of healthcare organisations and policy makers.
Participants demonstrated the ability to engage in complex decision making by
considering a number of different issues simultaneously. This included the impact of
the dilemma and the options available to them. In order to do this they applied ethical
principles, weighing the benefits and burdens to each person of each option within
the dilemma. Student nurses will therefore need to be appropriately prepared with
the skills to address such complex dilemmas once they have been accepted onto a
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nursing degree programme. They will also need to develop the self confidence to
contribute effectively and the courage to challenge others appropriately when the
situation requires it.
11.3b Recommendations for further research.
Nursing values and ethical decision making
Participants involved in this study were Senior Charge Nurses, Charge Nurses or
Staff Nurses working on a ward or department. Further research using a case study
is planned; a Senior Nurse with strategic level responsibilities within the organisation
will be interviewed using the same semi-structured interview process. Agreement in
principle has been granted and ethical approval is being sought.
Further research studies could to be undertaken within the UK primary care sector
and internationally, involving staff in both primary and secondary care settings, to
establish if the nursing values identified in this study are shared globally and across
care settings.
11.3c Moral dissonance.
A key theme that has emerged is that of moral distress; Corely (2002) presented a
model of moral distress based on a review of the literature, recommending that
further research be undertaken. It is evident from the findings in this thesis that whilst
nurses did find ways of contributing to the resolution of these dilemmas, they also
highlighted the distress or discomfort they experienced when they felt that the best
possible outcome for the patient was not achieved or when they came into conflict
with others in the context of meeting their duty of care. The changes in NHS
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provision have resulted in an increased risk of nurses experiencing moral distress as
services become driven by policy and organisational productivity objectives. The
increased demands placed on limited resources due to the increased number of
treatment options available and increased demand for care provision have been
highlighted in Chapter 7 of this thesis.
Moral dissonance has been identified within this study and in recent literature
(Cronqvist et al., 2006; Fairchild, 2010). It appears that, in some cases, experienced
nurses are able to recognise the dissonance between the ideal outcome and what is
achievable with the context of their practice, thus limiting the moral distress
experienced and the potential negative impact.
Research is therefore required in order to:
Identify ways to ensure the nursing voice is heard and respected at all levels
within the organisation from macro-level organisational policy making and
ways of delivering care to micro level decisions associated with individual
patient treatment, care and ethical decisions in practice; this may help to
reduce the moral distress experienced by nurses.
Identify strategies to help nurses address any residual moral distress, to avoid
any negative consequences.
Identify how experienced nurses are able to recognise and accept moral
dissonance, using this as a catalyst, and so limit the moral distress
experienced and improve outcomes.
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11.4 Dissemination of results.
This thesis will be available through the University of Huddersfield repository which
provides open access to the full text. All participants have received information on
how to access this so they are able to see how their accounts have contributed to
the findings of this research.
A minimum of two papers will be submitted to appropriate journals to facilitate
further dissemination. One will be a scholarly publication and the other will be aimed
at reaching nurses in clinical practice.
Abstracts will be submitted to nursing conferences, the RCN research conference
and the International Philosophy of Nursing conference, as these two attract different
audiences, both of whom may have an interest the study findings.
11.5 Reflection
A reflection of the process from the conception of the research aim to the writing of
the thesis has been undertaken. Gibbs (1988) reflective cycle was used to facilitate
this reflective process.
11.5a What happened?
Framing my Ideas
In the initial stages I was aware of the topic I wanted to explore, having spent
approximately 20 years working in acute medicine and older people’s services. I was
aware of the changes in health care provision and the increase in treatment options
available since my initial enrolment on the nurse register as an enrolled nurse. These
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changes had resulted in the need for nurses to make more and more complex
decisions, the most challenging of these were ethical in nature.
I had also been teaching ethics to undergraduate preregistration nursing students for
2 years; many of my students struggled to see how this would help them in their
practice as registered nurses. Ethical decision making was recognised in the ‘big’
questions, ‘life and death situations’, and some students perceived that doctors
made the important decisions and that nurses were only involved in the care that had
been prescribed. When exploring this further with students it became apparent that
students had observed nurses working in environments where, day-to-day, they
were faced with ethical decisions, however this had not been articulated to the
students and they had not recognised it.
The literature review
A literature review was undertaken to discover the current understanding of the topic
and a theoretical framework was developed to help with the understanding of the
concept of ethical dilemmas in nursing practice.
A further detailed search of the literature was undertaken and emergent themes
were identified. I had to be disciplined in both protecting time to undertake this and in
recording and storing the literature retrieved.
A proforma was used (see Appendix 3) to record the main findings from the critical
review of each piece of literature retrieved. This had been developed whilst
undertaking a Master’s degree. The need to develop this modified proforma was to
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enable different types of evidence used to be within the review of the current
literature. A wide variety of evidence is used as, within ethics, both philosophical
development of theories and empirical work have been undertaken.
Ethical approval
Ethical approval was sought and obtained from both the University of Huddersfield
and the National Research Ethics Committee for the NHS. To obtain approval
extensive documentation and a full explanation of the proposed study were required.
I also attended the meeting of the committee to respond to questions regarding the
study. Following approval, permission to access participants from The Trust was
sought and granted.
Progression monitoring
Progression monitoring was also required at key stages, at the end of years two and
three of the programme, as this was a part time PhD. Progression monitoring at the
end of year two required a written submission which was reviewed and feedback
provided on further development of the study.
Progression monitoring at the end of year three required both written submission and
oral presentation, to which members of the university staff and their postgraduate
research students were invited, and at which they could ask questions together with
the university appointed reviewers.
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The pilot study
The pilot study was undertaken prior to the progression point at the end of year 3
and involved staff from the university. Initial interviews were shorter than I had hoped
they would be, however, with experience my interviewing skills improved and I was
able to engage with the voluntary participants sufficiently to obtain rich data which
was later used to inform both the pilot study findings and the main study findings
(reflection was undertaken after each interview to facilitate this). Interviews were
audio recorded; it took a little time to get to grips with the MP3 recorder but once I
had practised a number of times this proved to be a suitable way of collecting the
narrative accounts provided by participants. I transcribed the pilot interviews, which
took at least a whole day each.
Once transcribed, the analysis could be undertaken and, for the pilot data, only a
thematic analysis was undertaken, using the software package NVIVO 8. It was the
first time I had used this type of package and, again, this was challenging at first but
as I became more practiced I was able to code the data more efficiently.
European Doctorate Students Research Conference
Findings from the pilot study were presented at the European Doctorate Students
Research Conference in September 2010. This involved travelling to Berlin where
the conference took place and meeting other doctoral students from across Europe. I
was able to discuss my work with others in a similar position to myself in the context
of undertaking doctoral studies. We compared our work in terms of topics, research
methods, expectations of our supervisors and institutions and the final oral
examination process.
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The study
Once NREC’s approval had been gained and a letter of access provided by the
research and development department of The Trust received, I was able to begin
recruiting participants from The Trust. The recruitment of participants involved
visiting wards and departments, speaking to the ward or department manager where
possible or the nurse in charge on that day, leaving a letter with them to explain the
research to be undertaken and a copy of the participant information sheet. I followed
this up with further telephone contact to arrange a time when I could visit and talk to
any registered nurses who might be interested in taking part. Nine participants were
recruited from a variety of areas. All were interviewed; one participant stopped the
interview and decided not to continue.
I reassured the participant that this was not a problem, the tape was stopped and I
asked the participant if there was anything I could do for her of if she felt she wanted
to access counselling. The participant wanted to contribute to the study but did not
want to continue with the interview. A long discussion about her experiences then
took place; this included how the participant felt about the nurse’s involvement, or in
some cases lack of inclusion in the decision making process, whilst having to
provide the care prescribed as a result if the decision. The participant was feeling
better and was happy for me to use my reflections and account of our conversation
as part of the final thesis.
Transcription of these interviews was undertaken by an audio typist as the time
involved was thought to be better spent reading and re-reading the transcripts whilst
listening to the recordings to facilitate in-depth knowledge of the interviews so to
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facilitate data analysis. Data analysis was undertaken using NVIVO 8 to code data;
thematic content and interactional analysis were undertaken.
Student conference
A keynote presentation was undertaken as part of the student research conference
held annually at the university as the theme was ethics in clinical practice (see
Appendix 9).
Final writing of the thesis
Completing the writing of the thesis was difficult and took a substantial length of time
with numerous drafts being discussed with supervisors. Sections of this had been
undertaken as the research progressed, however sections required revisiting and
developing for the final thesis.
11.5b What were you thinking and feeling?
Framing my ideas
In the initial stages I was excited that, having wanted to undertake research in this
field for many years, I was now embarking on this journey. At the same time,
however, there were feelings of anxiety, of ‘would my work make the grade?’
I knew that this was an opportunity to research what I wanted and that I might never
have this luxury again; I wanted to make the most of this.
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I hoped that this work would inform my role as Senior Lecturer and help me to inspire
others to practise ethically as student nurses and as registered nurses, in whatever
area they ultimately practised.
The literature review
I was familiar with this aspect of the research process as I had undertaken a
literature review for a recently awarded master’s degree. I was, however, surprised
at the limited range of empirical work I found into what I considered to be an
essential part of nursing practice, aspects of which have recently been further
identified as such by Francis (2013).
Ethical approval
I was fully aware of the requirement of the School ethics panel as I had been on the
ethics panel for two years by this time and was not concerned about the process; I
understood the importance of the role of the ethics panel and how feedback from the
panel could help to further develop the proposed research.
Progression monitoring
Whilst I recognise the importance of progression monitoring I felt that the extensive
form filling that this seemed to involve took me away from making the progress I
wanted with the research, particularly at the end of year one.
Monitoring at the end of year three was even more time consuming and my previous
frustrations re-emerged, however once I had completed the written submission and
prepared my oral presentation I began to see my work as a whole and was able to
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recognise the progress I had made. I found this motivating and helpful in forward
planning for the next 12 months.
The oral presentation was to a group of about 20 people and, although I was used to
teaching large groups of students, I remained anxious about this and felt vulnerable
at having to share my work with anyone other than my academic supervisory team. I
felt relieved and happy when this was over as it appeared to go well; the written
feedback, however, was provided on a form and was minimal. I felt disappointed as I
had hoped for constructive comments to help me question my work and develop it
further.
The pilot study
The pilot study was difficult as I was not confident that I would retrieve the data I was
looking for with the semi-structured interview questions I had developed. My anxiety
showed and knowing some of the participants for some time perhaps made me more
so, rather than making the process easier. My confidence increased with each
interview and the questions were modified as appropriate.
Initially I thought the data I was collecting would be insufficient and lacking depth as
many, but not all, of these accounts reflected my own experiences. However, as I
thematically analysed this data it soon became apparent that I had collected some
valuable data, with some participants expressing similar thoughts, feelings and
responses within the very different dilemmas they had faced.
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European Doctorate Students Research Conference
Attending this conference presented me with more than the challenge of presenting
my work. Unfamiliar with foreign travel and having never travelled abroad alone I
was filled with apprehension; managing to overcome some of these perceived
boundaries proved to be a positive experience and confidence building.
Meeting with others also studying at doctorate level was enlightening and others
showed interest in my work and I in the work of others. Confidence in our work, and
our ability in discussing this with others, further developed over the weekend.
The study
Entering environments (although they were in a hospital and I am familiar with the
hospital environment) in which I had never worked or knew anyone was difficult and I
was a little concerned about it. I did, however, have a colleague who worked in The
Trust and kindly came with me to meet the ward and department managers. Once I
had made the initial contact I felt more confident in contacting and meeting with the
managers and prospective participants.
Meeting and engaging with the participants was very rewarding; I felt like a nurse
again for the first time in a number of years, it reminded me of why I do the job I do
and the important role nurses play in the lives of others, especially when they are
vulnerable. I felt that I was able to very quickly build a rapport with participants.
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Engaging with the data and undertaking the analysis was rewarding and reminded
me why, firstly, I had decided to become a nurse and, again, how important this
aspect of professional nursing practice is.
Final writing of the thesis
This felt like the final endurance test, having had some episodes of ill health during
this time I was determined this was not going to stop me completing this thesis. The
support at this stage from both supervisors and colleagues was more than I could
have asked for and my appreciation of this cannot be expressed sufficiently.
11.5c What was good about the experience?
The good things about this experience are the people I have met, the things I have
learned and knowing what it is I need to do next.
The people who have supported me on this journey have proved to be the most
valuable resource available to me both professionally and personally; valuing my
work; discussing aspects of this and helping me increase the breadth of perspectives
from which I viewed things; supporting me to free up time to spend on the research
and writing of this thesis; an giving me space to rest and reflect when I needed it;
believing in me and my work when I did not; helping me to find my way through.
I have learned that, with hard work, commitment and the support of others, I can
develop new skills to further develop my research and contribute to the way nurses
act and are perceived by others. I have also learned that although I struggle with
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written English, it should not stop me from contributing in this way, as help is always
available.
I have, right at the end of this first stage of my journey, discovered it is possible to
make time for research. As the deadline approaches for the submission and each
draft requires more work than I had initially expected, I have found the time.
What was bad about the experience?
I was not able to make the time I wanted to complete this work and sometimes I felt it
would take forever; it has drawn me away from other things, such as meetings with
friends and family. I have, however, now found I am able to do this.
I felt that in the effort to support my progress with this study I had been excluded
from other opportunities to develop professionally and that, whilst I had hoped that it
would bring me closer to the research community at the university, it has served as
an obstacle.
11.5d What sense can you make of the situation?
The situation is one that many people go through and I do not think it is possible to
explain what it is about to someone who has not been there. I know that the support
of others and having friends on the same journey have been a great help to me, as
indicated above.
The rapport quickly developed with participants was, I think, because as I am
also a nurse, the participants felt at ease. As suggested in Chapter 6, there is
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a perceived shared value system amongst nurses and, therefore, the
understanding that there would be a shared understanding of their dilemmas.
I recognise it is something that I both wanted and needed to do both personally and
professionally and I now believe that I am in a better position to continue developing
as a researcher and make a contribution to understanding ethical practice and
reveal the voice of nurses working in the context of the changing health care system.
What else could have been done?
Progression monitoring
I should have followed up the oral presentation and made an appointment for further
feedback from the internal reviewers of my work than was available on the feedback
form issued by the university. This would have given me the opportunity to recognise
areas that could have been developed to strengthen the work and possibly increase
my confidence in this work.
European Doctorate Students Research Conference
I could have maintained contact with those I met at the conference. I could have
submitted abstracts to other conferences as my work progressed
The study
Data could have been collected from nurses working in other geographical locations,
Trusts or organisations providing secondary care. This may have strengthened the
findings of this study (Polit and Beck, 2008) as it has not been possible to exclude
that the values exhibited by the participants were not influenced by the organisation
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within which they were working. Participants did, however, have different
backgrounds and had worked in other organisations.
If it arose again what would you do?
I would undertake this as a full time course of study rather than a part-time one; I
think that I would have enjoyed it more than I have. As a full time student I would
have been more able to main the momentum, gained a richer understanding of the
topic and the participants’ experiences and probably felt part of the research
community within the university. I did not feel part of either the postgraduate
research community or the postgraduate student community, as a part-time student
and a full-time senior lecturer in the same institution, with the majority of my time
taken up with teaching and administrative work rather than balancing the two
effectively.
With regard to the research process, I do not think I would do things any differently in
respect of data collection and data analysis. For the literature review I would manage
my time differently and undertake this in blocks of time (several days at a time)
rather than in short bursts of a single day or afternoon.
I think that I could have made more of the opportunity to network and keep in touch
with the people I met at the European Doctorate Students Research Conference,
and taken up the opportunity to attend more conferences to meet others working in
the same field.
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11.6 Summary
This thesis details an exploratory enquiry into the contribution nurses make in the
resolution of ethical dilemmas in secondary care.
The purpose of the study was to identify the contribution nurses make to resolving
ethical dilemmas and what it was that formed the decisions and actions associated
with this. In order to establish this, a qualitative exploratory study was undertaken,
using a semi structured interview process to collect data.
Chapter 1 presents the background to the study and explains that the context of
secondary care has changed significantly over the last 20 years. These changes are
the consequence of technical developments and the increased number of treatment
options available for a variety of conditions and, consequently, the role of the nurse
has changed significantly (Storch et.al., 2004).
From examination of the literature retrieved to inform the background of this study, a
theoretical framework was developed (see Figure 1). The theoretical framework
used in this investigation shows the process the nurse might follow when addressing
dilemmas and begins with the identification of the dilemma or problem which is
triggered by the nurse’s moral conscience. Moral reasoning, based on the nurse’s
values and beliefs, informs the initial response to the situation. This is then justified
through ethical decision making and followed by the moral action which the nurse
has decided is the best available course of action in context.
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The nurse participants demonstrated that they believed that the welfare of the patient
is the most important aspect of the nurse’s role; that nurses should be prepared to
be accountable for their actions, promote patient autonomy; that the impact of any
action on ‘others’ should be considered and that nurses have a shared
understanding and a set of beliefs and values.
Nurses value people most of all and in the secondary care context that begins with
the patient; the virtues of compassion, honesty and trustworthiness are important in
developing these professional and ethical relationships which are required to
facilitate best possible outcomes for patients and others who are affected by
dilemmas the nurses face.
The aspect of the nurses’ behaviour required in order to facilitate moral action was
the importance of the professional relationships developed and maintained by nurses
in achieving the preferred outcomes for the patients and facilitating the resolution of
the ethical dilemmas. These relationships are with patients, families and other
members of the multidisciplinary team and facilitate collaborative working in
partnership to achieve moral action. Nurse participants highlighted how they work
with others and emphasised their role within the collaborative working that was
undertaken in each account.
Therefore, it is likely that nurses may use a combination of approaches to ethical
decision making and the indications from this exploratory study are that they use a
virtue based approach. The virtue based approach is complemented by the
development of key ethical relationships, developed and maintained between
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nurses, the patients for whom they are caring, the patients’ families and other health
and social care professionals involved in the interprofessional care delivered.
228
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Appendix 1
Literature selected for use in the development of the theoretical
framework
243
Appendix 1: Literature selected for use in the development of the theoretical framework
Author /date
Method Strengths Weakness Main point Significance
1. Almark 1998 Discussion Well constructed & referenced
Age Caring about the right things in the right way.
Caring as a virtue
2. Aroskar, et. al., 2004
Qualitative Focus groups 36 RNs
N = 36 Detailed analysis
Nurse participants all had 20 years plus experience
Looks at nurses potential involvement in Policy development
How policy contributes to moral distress
3. Banks, 2003
Discussion / evaluative In-depth evaluation of codes of ethics for social professions
Does not include nursing
Highlights some similarities limitations to these
‘ The code ‘
4. Bell 2003 Questionnaire N=9751% response rate
No such role currently in UK
Utility nurses role Resource allocation
5. Botes 2000a Integrated ethical decision making – health care team
Well organised and supported
Supports health care ethics rather than biomedical or nursing Need for moral agent
Ethical decision making collaborative working esp. nurse and Dr.
6. Botes 2000b Discussion Ethic of care V justice
Ethics of care and justice
Limits to two perspectives
Recommend that a balance between these two poles id required
7. Clará et al
2004
Cross sectional study N= 253 From 26 departments
Participants are surgeons
Youngest & most senior surgeons higher companion
Conflicting principle
8. Carter and Klugman 2001
Discussion
Well constructed and referenced
Philosophy of cultural engagement
Culture ,beliefs and values
244
Author /date Method Strengths
Weakness Main point Significance
11 Dierckx de Casterle, et. al., 2004
Discuses the contribution of two empirical studies
Both studies have Large sample size stable over time
Now 9 years old, changes in health care deliver has continued to change
Nurses use conventional methods when making ethical decisions
Challenges idea if ‘best for the patient’
9. Elgar and Harding 2002
Questionnaire 5pt Likert scale
N=127+168
Medical & law students Patient rights Patient autonomy
10. Herbert 1997 Discussion re stroke patients & DNR decision
Recognises the decisions making
Only considers Utilitarian & deontological approaches
Considers the dilemma from a number of perspectives
Uphold the role of the nurse int he decision making process
11. Hurst et al 2005 Survey Telephone interviews
N=344 64% response rate
Participants are Physicians
Avoided conflict Looked for assistance In decision-making Sort to protect their integrity
Shared decision making
12. Jenkin and Millard 2006
Discussion / reflective approach
Considers the complexity and perspectives Well referenced
7 years old Patients best interest Acknowledges that some declemmas need to be addressed quickly
13. Kain 2007
Literature review Well documented search, well developed discussion
Care of dying babies Moral distress during this & the impact n the Nurse
Calls for framework of primary care ethics due to increase in complex dilemmas
14. Kalvemark, et.
al., 2004
Qualitative Focus groups
N- = 3 focus groups 4-7 in each 1.3 – 2 hours
Includes The need for support & structures re ethical decision making
Conclusion is nurses use conventional approach to ethical decision making
15. Martin 2004 Used policy documents to examine the language of nursing ethics
Examines both internal and external influences on the context of primary care
Primary care
245
Author /date
Method
Strengths
Weakness
Main point
Significance
16. Noureddine 2001
Discussion Nursing theory & nursing ethics
The discussion of the impact of the context is limited
Highlight nursing values Recognises the importance of caring
17. Oberle & Hughes 2001
Qualitative, interview Thematic analysis
Drs =7 Nurses = 14
More nurses than Doctors - not justified
Dr make the decisions Nurses implement the decisions leading to moral distress
Challenged by new findings
18. Pavlish et. al., 2011
qualitative descriptive study
70 participants No face to face contact with participant Participants recruited from ethics conference (bias)
Relates to aspects raised by participants
The nurses role in EDM Conflict
19. Redman and Fry 2000
Five studies 4 specialties
Five studies Looking at ethical conflict described by nurses
Less ethical conflict described more moral distress and unresolved dilemmas
20. Salloch, and Breitsameter 2010
Qualitative Grounded theory
10 interviews – saturation reached
Nurses & volunteers This therefore is not based purely on nurses and does not involve the full range of people working in the hospice
Importance of being non judgmental
Conflict been the patients’ wishes and values and those of the participant (nurse)
21. Tourjuul &
Sørlie 2006
Qualitative Phenomenological –hermeneutic interpretation
Small of 10 however in depth interviews & analysis produced rich data
Surgical nurses only
Norway Tension between nurses and the limits imposed by organizational objectives
Pt Records nad documentation by nurses indicate that nurses put biology over biography
246
Appendix 2
Literature selected for inclusion in the literature review
247
Appendix 2: Literature selected for inclusion in the literature review
Author /date
Method
Strengths
Weakness
Main point
S Significance
1. Aroskar, et. al., 2004
Qualitative Focus groups 36 RNs
N = 36 Detailed analysis
Nurse participants all had 20 years plus experience
Looks at nurses potential involvement in Policy development
How policy contributes to moral distress
2. Banks, 2003
Discussion / evaluative In-depth evaluation of codes of ethics for social professions
Does not include nursing
Highlights some similarities limitations to these.
‘ The code ‘
3. Botes 2000a Integrated ethical decision making – health care team
Well organised and supported
Supports health care ethics rather than biomedical or nursing Need for moral agent
Ethical decision making collaborative working esp. nurse and Dr.
4. Botes 2000b Discussion Ethic of care V justice
Ethics of care and justice
Limits to two perspectives
Recommend that a balance between these two poles id required
5. Corely 2002
Philosophical discussion
Will structured and referenced
Does not identify how the supporting literature was selected
Proposes theory of moral distress
6. Dierckx de Casterle, et. al., 2004
Discuses the contribution of two empirical studies
Both studies have Large sample size stable over time
Now 9 years old, changes in health care deliver has continued to change
Nurses use conventional methods when making ethical decisions
Challenges idea if ‘best for the patient’
7. Dierckx de Casterle, et. al., 2010
Grounded theory N =18 registered nurses
Did not reach saturation.
Nurses contribute to the care process (good)
Decision making is taken on by senior nurse & physician.
248
Author /date
Method
Strengths
Weakness
Main point
Significance
8. Donker and
Andrews 2011
Qualitative Anonymous self administered questionnaire
N=200 Loss of depth which may have been retrieved using other methods
Local beliefs and organisational requirements limit the application of ethical codes
Highlights how cultural values and norms influence ethical practice
9. Hardington,
2004
Discussion Well structured Balanced discussion Reflection
Search strategy is unclear
Nurses as part of a moral community
Moral distress & relates to tension with the ‘system’
10. Heikkinen, et
al., 2006
Qualitative, international.
23 focus groups N= 138 participants in total Several researched
Focus groups my stifle disclosure of some ‘unethical practices’
Obstacles to implementing codes
7 barriers identified Nurses MDT Patient families Organization Nursing profession Society /health policy
11. Hyde et.al.,
2005
Discourse analysis
45 patient records
Patient records can be limited
Little evidence within documentation of nurses interpersonal interactional with patients and the facilitation of patient autonomy.
Highlights that record indicate that nurses put ‘biology over biography’
12. Liaschenko and Peter, 2004
Discussion paper Discusses the limitations of professional ethics
10 years old – still relevant though
Identifies the ‘ethic of work’ and nursing as work
13. Kain 2007
Literature review Well documented search, well developed discussion
Care of dying babies Moral distress during this & the impact n the Nurse
Policy / resources limiting action
14. Kalvemark, et.
al., 2004
Qualitative Focus groups
N- = 3 focus groups 4-7 in each 1.3 – 2 hours
Includes The need for support & structures re ethical decision making
Conclusion is nurses use conventional approach to ethical decision making
249
Author /date
Method
Strengths
Weakness
Main point
Significance
15. Lamb &
Sevdalis, 2011
Discussion paper Effective discussion Well referenced current
Editorial Increased nurse lead decision making Need for increased research.
Collaberation
16. Long- Sutehall
et al., 2011
Qualitative Grounded theory N= 13
Current Semi-structured interview vignettes
Nurse involvement increases when implementing the decision
Context Collaboration
17. Oberle &
Hughes, 2001
Qualitative, interview Thematic analysis
Drs =7 Nurses = 14
More nurses than Doctors - not justified
Dr make the decisions Nurses implement the decisions leading to moral distress
Challenged by new findings
18. Pavlish et. al.,
2011
Qualitative descriptive study.
70 participants qualitative descriptive study
No face to face contact with participant Participants recruited from ethics conference
Relates to aspects raised by participants
The nurses role in EDM Conflict
19. Peter, et. al.,
2004
Literature review Critical incident Questionnaire
18 papers Dated About nurses resistance to ethical action Recommendation how to address this
Nurses resist situation where there is moral conflict Lots about power
20. Redman and
Fry, 2000
Five studies 4 specialties
N=164 N=97 N=118 N=91 N=470
Looking at ethical conflict described by nurses
Less ethical conflict described more moral distress and unresolved dilemmas
21. Salloch, and
Breitsameter, 2010
Qualitative Grounded theory
10 interviews – saturation reached
Nurses & volunteers Not based purely on nurses / does not involve the full range of people working in the hospice
Importance of being non judgmental
Conflict been the patients’ wishes and values and those of the participant (nurse)
250
Author /date
Method
Strengths
Weakness
Main point
Significance
22. Tourjuul &
Sørlie, 2006
Qualitative Phenomenological –hermeneutic interpretation
Small of 10 however in depth interviews & analysis produced rich data
Surgical nurses only
Norway Tension between nurses and the limits imposed by organizational objectives
Pt Records nad documentation by nurses indicate that nurses put biology over biography
23. Vandrevala et.
al., 2006
Interpretive phenomenology Focus groups
N= 48 older people
All UK Limited acknowledgement of limitations
‘patients’ views on ethical decision making
Themes match some of those used by nurses
24. Ulrich, et.al.,
2010
Postal survey N= 422 returned 52% response rate
Closed questions
‘Nurses face daily ethical challenges’
The need for ethical related interventions
25. Varcoe et. al.,
2004
19 Focus groups N=87 Focus groups my stifle disclosure of some less mainstream opinions
Presents a ‘new’ understanding of nursing ethics
Working ‘in between’ Away of being and action as moral agent.
26. Verpeet, et al.,
2004
Qualitative 8 Focus groups
N = 50 thematic analysis audit trail maintained
Some limitations identified within the data collected
Nurses view on ethical codes
Useful for a number of reasons detailed in the paper
27. Wolf and
Zuzelo, 2007
Qualitative Critical incidents
N = 20 Range of experience All nurses
No acknowledgment of limitations
Never again stories Disempowered nurses
Talks expensively about the constrains on nursing action & disempowerment
251
Appendix 3
Review Framework
252
Review Framework Proforma
Questions Yes / No / NA
Comments
1 The researcher
What is their back ground?
2 The problem
Is It clearly stated?
Dose this give a new creative slant/ position
Does it relate to nursing practice / education
3 Literature review
Relevant topic?
Is it comprehensive?
Is current and up-to-date material included?
Are classic studies cited?
Dose the summary accurately capture the crucial aspects of the literature and relevance to the study?
4 The design
Dose the design statement convey the type of report being discussed?
Are theoretical frameworks discussed?
Are the hypotheses stated clearly?
Straight forward description of the plan with rationale?
Could other replicate the study based on information provided?
Are technical terms clearly defined?
5
Data collection
Is the method selected discussed?
Is rationale provided?
Does it stand up to criticism?
Are details of sampling methods / sizes clear?
Are details of special instruments given? Questionnaires, interview schedules, measuring techniques
Is reliability and validity discussed?
6 Ethical issues
Are procedures ethical?
Is informed consent obtained?
253
Adapted from Burns and Grove’s (1987) model and Morrison’s (1991)
Confidentiality safeguarded?
Ethical clearance obtained?
Respect for academic property upheld/?
7
Data analysis
Is the method selected appropriate for the data?
Is it clearly described?
Are the findings clearly presented?
8
Reporting the results
Dose the title identify the type of study?
Is the abstract clear?
Has the researcher been honest?
Is non-discriminatory language used?
9. OR
Discussion / argument
Are the results clearly discussed?
Are the results adequately discussed?
Is the argument clearly constructed
Are some aspects of the discussion / argument emphasised more than others, if so is this justified?
10 Conclusion / recommendations
Are the conclusions justified
Are the conclusions linked to the original purpose?
Have new insights been uncovered?
Have new research questions emerged?
Are the recommendations feasible?
Are possible limitations of the study if identified?
11 What are the strengths of t he study / paper
12 What are the limitations of the study / paper?
254
Appendix 4
Participant information (pilot study)
255
What the nurse does?
A narrative approach to understanding the nursing contribution to the
resolution of ethical dilemmas in the context of nursing practice.
Information sheet You invited to take part in a research project that is exploring the nursing contribution to the resolution
of ethical dilemmas in the context of nursing practice. Please take the time to read this leaflet through
and do not hesitate to ask if there is anything that is not clear or if you would like more information. It
is important that before deciding to take part you fully understand why this research is being
undertaken and what it will involve.
What is the purpose of the study? The purpose of this research is to identify how registered nurses working within secondary care
provision view their personal and professional contribution to achieving the satisfactory resolution of
ethical dilemmas within the context of their nursing practice.
.
Why have I been chosen and what will I have to do?
You have been chosen because you work as a registered nurse within the secondary care
envioronment.
I would like to collect your perspective on the contribution you make within the context of your nursing
practice. This will involve an individual meeting during which time we will talk about your experiences
and contributions. The narrative provided by you will be recorded for transcribing at a later date prior
to analysis. It is envisaged that the meeting will last will last approximately 30 minutes to one hour.
Can I withdraw from the study?
If you do decide to take part you are still free to withdraw at any time and without giving a reason.
Who is organising and funding the study?
The research is funded and supported by the University of Huddersfield.
The researcher is Nichola Barlow who is a part time PhD student at the University. Nichola will
correspond with you at all stages of the study. Nichola will meet with you discuss your contribution
and record the meeting. The transcribed data will be returned to you for verification prior to analysis.
If you require any further information about the project then please contact Nichola Barlow at the
University of Huddersfield email:[email protected], or telephone 01484 473472.
You will be able to have access to the completed report once the research is finished the writing up
process has been completed.
Thank you
256
Appendix 5
Participant consent form (pilot study)
257
What the nurse does?
A narrative approach to understanding the nursing
contribution to the resolution of ethical dilemmas in
the context of nursing practice.
Consent to participate
Please initial the box
1. I have read and understand the information sheet for the above study, provided. I have had the opportunity to consider the information, ask questions and
have these answered satisfactorily.
2. My participation in this study is voluntary and I understand that I am free
to withdraw from the study without giving a reason.
3. I understand that the collected narrative will be recorded and on completion
of the research the recordings will be destroyed along with the
original questionnaire responses.
4. I understand that the original recorded narratives will not be shared with
any individuals apart from the researcher, audio typist engaged to transcribe
the data and the study supervisors.
5. I understand that the final report, containing anonymous quotations
may be used for the publication of peer reviewed journal articles and
conference presentations.
6. I agree to participate in this study.
------------------------------------------------ ------------------------------------------ ----------------------
Participant Name Signature Date
----------------------------------------------- ------------------------------------------- ---------------------
Researcher Signature Date
258
Appendix 6
Participant information
259
What the nurse does? Exploring the nursing contribution to the resolution of ethical dilemmas in the context of
nursing practice.
Information sheet
You are invited to take part in a research project that is exploring the nursing contribution to the resolution of
ethical dilemmas in the context of nursing practice. Please take the time to read this leaflet through and do not
hesitate to ask if there is anything that is not clear or if you would like more information. It is important that before
deciding to take part you fully understand why this research is being undertaken and what it will involve.
What is the purpose of the study?
Nurses face ethical dilemmas as part of their nursing practice and it is often these that cause the greatest
concern for the patient, their family and the nurse. It is therefore important that we are able to understand what,
currently, registered nurses contribute to addressing these dilemmas as they occur.
Why have I been chosen and what will I have to do?
You have been chosen because you work as a registered nurse within the secondary care environment.
I would like to collect your perspective on the contribution you make within the context of your nursing practice.
This will involve an individual meeting during which time we will talk about your experiences and contributions.
The narrative provided by you will be recorded for transcribing at a later date prior to analysis. It is envisaged that
the meeting will last will last approximately 30 minutes to one hour.
Can I withdraw from the study?
If you do decide to take part you are still free to withdraw at any time and without giving a reason. If I choose to
withdraw from the study any data collected will be retained for use within the study.
Who is organising and funding the study?
The research is funded and supported by the University of Huddersfield.
The researcher is Nichola Barlow who is a part time PhD student at the University. Nichola will correspond with
you at all stages of the study. Nichola will meet with you discuss your contribution and record the meeting. The
transcribed data will be returned to you to confirm you are happy with it prior to analysis.
If you require any further information about the project then please contact Nichola Barlow at the University of
Huddersfield email:[email protected], or telephone 01484 473472.
You will be able to have access to the completed report once the research is finished the writing up process has
been completed.
Counselling Services
If you require support or counselling as a result of disclosing sensitive or distressing situations you may access
the staff cancelling services via the occupational health department
Confidentiality Anonymity of participants will be maintained throughout the study. All data collected will be
treated confidentially; each participant will be allocated a reference number in order to maintain confidentiality.
However disclosure may be required where unprofessional or illegal practice is identified.
Thank you
260
Appendix 7
Participant consent form
261
What the nurse does?
Exploring the nursing contribution to the resolution of ethical dilemmas in
the context of nursing practice.
Consent to participate
2. I have read and understand the information sheet for the above study provided. I have had the opportunity to consider the information, ask questions and
have these answered satisfactorily
2. My participation in this study is voluntary and I understand that I am free
to withdraw from the study without giving a reason.
3. If I choose to withdraw from the study any data collected will be retained for use
within the study.
4. I understand that the collected narrative will be recorded and on completion
of the research the recordings will be destroyed along with the
original questionnaire responses.
5. I understand that the original recorded narratives will not be shared with
any individuals apart from the researcher, audio typist engaged to transcribe
the data and the study supervisors.
6. I understand that the final report, containing anonymous quotations
may be used for the publication of peer reviewed journal articles and
conference presentations.
7. I agree to participate in this study
------------------------------------------------ ------------------------------------------ ----------------------
Participant Name Signature Date
----------------------------------------------- ------------------------------------------- ---------------------
Researcher Signature Date
262
Appendix 8
European Doctorate Students Research Conference,
Abstract and PowerPoint presentation
263
EDCNS 2010 Abstract Form 11th European Doctoral Conference in Nursing Science
Berlin, Germany, 17 - 18th
September 2010
Title
What the Nurse does
Exploring the nurses contribution to the resolution of ethical dilemmas in secondary care - the pilot study
Authors
Nichola Ann Barlow PhD Student
School of Human and Health Sciences. The University of Huddersfield, Queensgate, Huddersfield. HD1 3DH
E-mail: [email protected]
Abstract Introduction Nurses face ethical dilemmas as part of their nursing practice and it is often these that cause the greatest concern for the
patient, their family and the nurse (Storch 2004, DH,1999.) . It is therefore important that we are able to understand what,
currently, registered nurses contribute to addressing these dilemmas as they occur.
Aim of the study Nurses face ethical dilemmas as part of their nursing practice and it is often these that cause the greatest concern for the
patient, their family and the nurse. It is therefore important that we are able to understand what, currently, registered nurses
contribute to addressing these dilemmas as they occur
Methods This is a qualitative study using audio recording of semistructured interview to collect narrative data from participants (Polit
and Beck 2006). A two phased analysis was undertaken firstly a thematic approach was used followed by a narrative
analysis designed to examine the cultural dimensions within the clinical setting (Burns and Grove 2001).
Results This pilot study using a sample of three participants revealed was undertaken to allow the testing of the questions used in the
interviews. This also allowed the researcher to develop the skills required for undertaking data collection using this method.
Three themes emerged from the data:
Authority – Organisational
Nurse – physician relationship
‘Best for the patient’
Discussion incl. Conclusion Participants identified and discussed conflicts that have arisen between the organisational objectives, procedures or protocol
and that which was thought to be ‘best for the patient’. Non of the participant discussed how they had established what was
‘best for the patient’ although this, for participants two and three, become a dominant objective in their accounts
Practical relevance As a researcher this pilot study highlighted the importance of developing the appropriate interviewing skills required for data
collection and appropriate wording of questions to illicit the required data from participants prior to undertaking the main
study.
Research implications The results of the data analysis have identified three key areas identified by registered nurses in relation to ethical dilemmas
where further research would be beneficial
References Burns N & Grove S K (2001) The Practice of Nursing Research; Conduct, Critique and Utilisation Philadelphia: W B
Saunders
Polit D F, Beck C T (2006) Essentials of Nursing Research (6th Edition ) Lippincott Williams & Wilkins
Storch, J. L. (2004) towards a moral horizon. Nursing Ethics for Leadership and Practice, Toronto Pearson.
Department of Health (DOH) (1999) Making a difference. Strengthening the nursing, midwifery and health visiting
contribution to health and healthcare. London Department of Health Publications.
264
Power Point Presentation .
265
266
267
268
269
270
271
272
273
274
275
Appendix 9
Under graduate student research conference Department of Health Sciences
PowerPoint presentation
276
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277
278
279
280
281
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283
284
285
286
287
288
289
290
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